M

1
MM Conference

• 9/16/08

2
MM Conference

• BJ
• 46 y/o Female with recently dxed with Stage IV
  rectal cancer, metastases to periaortic lymph
  nodes presently receiving radiation therapy and
  concomitant chemotherapy

3
MM Conference

• Initially presnted to ER with diarrhea, every
  hour for the last 12 hours refractory to Imodium
• Morning of admission started to complain of
  dizziness and weakness
• C/O mild lower abdominal pain
• No radiation
• Dull in quality
• No aggravating/alleviating factors
• No Nausea, No vomiting, No Unusual food, No ill
  contacts

4
MM Conference

• PMHx-Htn, Hyperlipidemia, GERD, Rectal Ca
• PSHx- Port-A-Cath, Cardiac catherization with
  unremarkable findings
• FHx- Mother-Uterine cancer
• SHx-32 pack year, occasional alcohol, no IVDA
• Allergies-NKDA

5
MM Conference

• Vitals- 36.1 P-120 BP-75/53 O2-100 2L
• Gen-Lethargic, AAOx3
• Skin-Poor skin turgor
• HEENT-PERRL, NC/AT
• CVS-Sinus Tachycardia
• LUNG-CTAB
• Abd- Soft, ND, NT, BS, no mass, no scars,
  guarding lower abdomen
• Neuro- no focal deficit

6
MM Conference

• Labs
• Na-134 K-3.0 Cl-100 CO2-19 BUN-31 Crea 1.6
  Glu-132
• WBC-11 Hgb-8.6 Hct-25 Plt-189
• Lactate-3.1

7
MM Conference

• A/P
• 46 y/o F with refractory diarrhea most probably
  secondary to chemotherapy infusion
• Admitted to Medical Oncology service
• Hold 5FU
• Stool- c. diff, wbc, ova parasite, culture
• IV hydration
• Octreotide

8
MM Conference

• Hospital Course
• All Stool samples negative
• Responded appropriately to IVF and cessation of
  5FU
• Intermittent fevers
• Empiric ABx started
• No positive cx
• Fever spikes eventually resolved

9
MM Conference

• HD8
• Now started to c/o intermittent nausea with
  abdominal distention
• No vomiting, No fevers, No Chills
• Loose stools continued throughout hospital
  course, less frequent
• GI, Surgical Oncology consulted

10
MM Conference

• Vitals- AVSS
• Gen- general discomfort, AAOx3
• HEENT-PERRL, neck-supple
• CVS-RRR
• Lung-CTAB
• ABD-Soft, mild distention, lower abdominal
  distention, BS
• guarding, no rebound tenderness
• Rectal- hard, immobile/fixed mass, at tip of
  finger, minimal lumen, no stool, no blood

11
MM Conference
12
MM Conference

• GI-
• Plan- colonoscopy with possible stent placement
• Surgical Oncology
• Evaluate for new onset obstruction and possible
  resection if proper response to chemo radiation

13
MM Conference

• HD9
• Pt continued to be distended, with loose stool,
  BS, ? Flatus
• Colonoscopy cancelled due to hypokalemia
• HD10
• Colonoscopy performed
• Unable pass stent, procedure aborted
• Patient Markedly distended in recovery room,
  diaphoretic

14
MM Conference
15
MM Conference

• Surgical Oncology
• Called to evaluate
• Abdomn- soft to firm, distention, No bowel
  sounds,
• Diffuse tenderness, rebound tenderness
• Pneumoperitoneum
• Patient taken to OR for exploration

16
MM Conference

• Post-Op Closed loop obstruction
• Procedure Exploratory laparotomy/Colonic needle
  decompression/ Transverse loop colostomy
• Markedly distended colon
• Distednd small bowel
• No obvious area of perforation
• Area of denuded bowel in the tansverse colon
• Split in transverse colon upon handling
• Oversewed
• EBL-minimal
• Complications-none
• Drain-none

17
MM Conference

• Post-Operative course
• No complications from surgery
• Steady increase in creatinine
• Found to be due to obstruction of Left Ureter
  from Rectal mass
• Left Nephrostomy tube placed
• Discharged on POD 7
• Tolerating Regular diet
• Good ostomy output
• Crea decreasing
• F/U with Urology and Surgical Oncology

18
MM Conference

• Morbidity
• Perforation after colonoscopy
• Closed loop obstruction
• Competent Ileocecal valve

19
MM Conference

• Function of the Ileocecal Valve
• First is to control the flow between these two
  areas to serve as a barrier to prevent the
  bacteria laden contents of the large bowel from
  contaminating the small intestine. 
• The second function is to keep the contents in
  the small intestine long enough for all digestive
  processes to be completed.

20
MM Conference

• Thought to have sphincteric functions
• Distention of the terminal ileum causes
  relaxation of the ileocecal valve
• Distention of the colon causes increased tone
• Cecal distention with possible perforation
• Law of LaPlace

21
MM Conference

• Law of LaPlace states in a long pliable tube,
  the site of largest diameter requires the least
  pressure to distend.
• Hence, in a patient suffering a distal large
  bowel obstruction, in the setting of a competent
  ileocecal valve, the cecum is the most common
  site of perforation