A thin and ill appearing 26-year-old man presents to the emergency department (ED) with fevers, chills, severe abdominal pain, and a rigid abdomen. While doing a history and physical, it is noted that he has a history of ulcerative colitis. What would be indications that stoma creation would be more appropriate than a primary anastomosis in this patient?
Patients with inflammatory bowel disease are often malnourished. Abdominal pain and obstructive symptoms may decrease oral intake. Diarrhea can cause significant protein loss. Ongoing inflammation produces a catabolic physiologic state. Parenteral nutrition should be strongly considered early in the course of therapy for either Crohn disease or ulcerative colitis. The nutritional status of the patient also should be considered when planning operative intervention, and nutritional parameters such as serum albumin, prealbumin, and transferrin should be assessed. In extremely malnourished patients, especially those who are also being treated with corticosteroids, creation of a stoma is often safer than a primary anastomosis.
A 24-year-old woman presents to the ED with fever, severe abdominal pain with guarding on palpation, and a history of 5 days of bloody stools. She has a history of ulcerative colitis. What are the indications for emergency surgery for ulcerative colitis?
Emergency surgery is required for patients with massive lifethreatening hemorrhage, toxic megacolon, or fulminant colitis who fail to respond rapidly to medical therapy. Patients with signs and symptoms of fulminant colitis should be treated aggressively with bowel rest, hydration, broad-spectrum antibiotics, and parenteral corticosteroids. Colonoscopy and barium enema are contraindicated, and antidiarrheal agents should be avoided. Deterioration in clinical condition or failure to improve within 24 to 48 hours mandates surgery.
A 55-year-old woman with a history of long-standing Crohn disease presents to the clinic with a 1 -month history of abdominal pain and a new area of induration, fluctuance, and foul-smelling drainage from a former midline incision. What are the most common indications for surgery for Crohn disease?
The most common indications for surgery are internal fistula or abscess (30-38% of patients) and obstruction (35-37% of patients). Crohn disease of the large intestine may present as fulminant colitis or toxic megacolon. In this setting, treatment is identical to treatment of fulminant colitis and toxic megacolon secondary to ulcerative colitis. Resuscitation and medical therapy with bowel rest, broad-spectrum antibiotics, and parenteral corticosteroids should be instituted. If the patient's condition worsens or fails to rapidly improve, total abdominal colectomy with end ileostomy is recommended.
A 23-year-old man presents to the clinic with severe pain on defecation that began 2 months ago. He has tried conservative management at home with sitz baths but his pain has become so severe that he has started to restrict how much he eats to prevent having bowel movements. On rectal examination, a fissure is found. What would indicate that this fissure from Crohn disease?
The most common perianal lesions in Crohn disease are skin tags that are minimally symptomatic. Fissures are also common. Typically, a fissure from Crohn disease is particularly deep or broad and perhaps better described as an anal ulcer. These fissures are often multiple and located in a lateral position rather than anterior or posterior midline as seen in an idiopathic fissure in ano. A classic-appearing fissure in ano located laterally should raise the suspicion of Crohn disease.
A 65-year-old man presents to the ED with fevers, abdominal pain, and bloody stools for the past 2 days. On CT scan he is found to have diverticulitis with scant free air and a small fluid collection associated with the sigmoid colon. What is the etiology of diverticulosis?
The majority of colonic diverticula are false diverticula in which the mucosa and muscularis mucosa have herniated through the colonic wall. These diverticula occur between the teniae coli, at points where the main blood vessels penetrate the colonic wall (presumably creating an area of relative weakness in the colonic muscle). They are thought to be pulsion diverticula resulting from high intraluminal pressure. The most accepted theory is that a lack of dietary fiber results in smaller stool volume, requiring high intraluminal pressure and high colonic wall tension for propulsion. Chronic contraction then results in muscular hypertrophy and development of the process of segmentation in which the colon acts like separate segments instead of functioning as a continuous tube. As segmentation progresses, the high pressures are directed radially toward the colon wall rather than to development of propulsive waves that move stool distally. The high radial pressures directed against the bowel wall create pulsion diverticula.
Click to expand