Case Presentation

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Case Presentation

• 64 year old lady
• 8 week history
• Malaise
• Left sided back pain
• Left sciatica
• Right groin pain

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Case Presentation

• Bloods
• WCC 25
• CRP 300
• CT scan ordered

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CT Scan
Gas in the portal system
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CT Scan
Gas in the IMV
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CT Scan
Gas in the sigmoid mesentery
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CT Scan
Diverticulitis
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Background

• 77 year old lady.
• PMH
• COPD
• PAF
• Previous appendicectomy, oesophagitis
• Rheumatoid arthritis
• DHx
• Aspirin, lansoprazole, frusemide, amlodipine.
• SHx
• Smokes 3 cpd with 60 pack year history.

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Presentation

• Attended AE on 28/9/03 with fall ?cause.
• Was on floor for gt12 hours.
• Sustained fracture to left neck of femur and
  admitted under orthopaedics.

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Post Op Course 1

• 30/09/03
• Left Thompsons hemiarthroplasty
• 1/10/03
• Patient doing well.
• Post op bloods Na 133, K 3.6, Ur 3.6, creat 53
• 2/10/03
• Hb 9.0, SaO2 87 air. IVI stopped and patient
  allowed to eat and drink

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Post op course 3

• 07/10/03
• Increased abdominal distension
• Sit out, drip and suck, surgeons to review.
• N/saline 40mmol kcl prescribed
• Na 137, K 2.6, Ur 8.1, Creat 48
• Surgical review
• Increased abdominal pain, no nausea
• Abdomen soft, non-tender and distended
• PR - empty

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Post op course 5

• 09/10/03.
• Prescribed 8 Hourly fluids, 1L given over 16
  hours Na 148, K 2.6
• AXR Size of caecum over 14 cm, but abdomen only
  mildly tender.
• Reviewed by on-call surgical team.
• What would you do now?

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Neostigmine

• Parasympathomimetic drug
• Turegano Fuentes et al, Dis Colon Rectum, 1997
  Nov40(11)1353-7
• Resolution in 75 after single iv dose. (N16)
• Trevisani et al, Dis Colon Rectum, 2000
  May43(5)599-603
• Complete resolution occurred in 26 out of 28
  patients
• Time to pass flatus 30 seconds to 10 minutes
• No adverse effects or complications were noted
• Ponec RJ, Saunders MD, Kimmey MB, Neostigmine for
  the treatment of acute colonic pseudo-obstruction.
  
• RCT N21, 10/11 neostigmine patients resolved,
  0/10 saline responded, 7/10 in saline group
  responded when crossed over.

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Percutaneous Endoscopic Caecostomy

• Salm R et al, Surg Endosc. 19882(2)92-95
• Successful outcome in 2 patients with failed
  conservative management
• Ramage JI et al, Gastrointest Endosc. 2003
  May57(6)752-5
• 5 case reports. No mortality or surgical
  intervention in any patient. Tube remained in
  situ in 3 patients, removed after 10 weeks in 1
  patient.

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Endoscopic decompression

• Gellar et al. Gastrointest Endosc. 1996
  Aug44(2)144-50.
• Overall clinical success was 88 (N50) . 82
  required just one treatment
• Success rates improved with placement of
  decompression tube.
• Iatrogenic perforation rate 2

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