Inflamed Diverticulum Research Articles

Acute Colonic Diverticulitis: CT Findings, Classifications, and a Proposal of a Structured Reporting Template.

Acute colonic diverticulitis (ACD) is the most common complication of diverticular disease and represents an abdominal emergency. It includes a variety of conditions, extending from localized diverticular inflammation to fecal peritonitis, hence the importance of an accurate diagnosis. Contrast-enhanced computed tomography (CE-CT) plays a pivotal role in the diagnosis due to its high sensitivity, specificity, accuracy, and interobserver agreement. In fact, CE-CT allows alternative diagnoses to be excluded, the inflamed diverticulum to be localized, and complications to be identified. Imaging findings have been reviewed, dividing them into bowel and extra-intestinal wall findings. Moreover, CE-CT allows staging of the disease; the most used classifications of ACD severity are Hinchey's modified and WSES classifications. Differential diagnoses include colon carcinoma, epiploic appendagitis, ischemic colitis, appendicitis, infectious enterocolitis, and inflammatory bowel disease. We propose a structured reporting template to standardize the terminology and improve communication between specialists involved in patient care.

Acute Ileal Diverticulitis: Computed Tomography and Ultrasound Findings

Acute ileal diverticulitis is a rare disease mimicking acute appendicitis. Inaccurate diagnosis with a low prevalence and nonspecific symptoms leads to delayed or improper management. This retrospective study aimed to investigate the characteristic sonographic (US) and computed tomography (CT) findings with clinical features in seventeen patients with acute ileal diverticulitis diagnosed between March 2002 and August 2017. The most common symptom was abdominal pain (82.3%, 14/17) localized to the right lower quadrant (RLQ) in 14 patients. The characteristic CT findings of acute ileal diverticulitis were ileal wall thickening (100%, 17/17), identification of inflamed diverticulum at the mesenteric side (94.1%, 16/17), and surrounding mesenteric fat infiltration (100%, 17/17). The typical US findings were outpouching diverticular sac connecting to the ileum (100%, 17/17), peridiverticular inflamed fat (100%, 17/17), ileal wall thickening with preserved layering pattern (94.1%, 16/17), and increased color flow to the diverticulum and surrounding inflamed fat on color Doppler imaging (100%, 17/17). The perforation group had a significantly longer hospital stay than non-perforation group (p = 0.002). In conclusion, acute ileal diverticulitis has characteristic CT and US findings that allow radiologists to accurately diagnose the disease.

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

S2747 Malignant Peritoneal Mesothelioma Seen on MRI Enterography During IBD Colitis Investigation in a 32-Year-Old Non-Asbestos Exposed Female Healthcare Worker

Introduction: This case describes an unexpected diagnosis of a malignant peritoneal mesothelioma (MPM) in a 32 y/o female physician without any known asbestos exposure. She presented to our department with a prior diagnosis of non-celiac gluten intolerance and intermittent but worsening left-sided abdominal pain for over 20 years. Several CTs suggested findings associated with IBD-related etiology and IBD specialist consultation was advised. After negative EGD/colonoscopy, an MRI Enterography revealed a small enhancing nodule suggestive of peritoneal malignancy. Pathology report after biopsy revealed a biphasic MPM. This case highlights the insidious nature of MPM and adds to the body of literature suggestive of IBD-mimicking symptomatology associated with this disease. Case Description/Methods: A 32 y/o F presented with chronic intermittent left-sided abdominal pain and gluten intolerance. Throughout her life, she reports 2-week periods of abdominal pain that is usually dull and sometimes sharp. The pain is focused LUQ with occasional LLQ pain. This is worsened by acute angle bending and deep palpation to the area. The patient still experiences pain despite a gluten-free diet. EGD is negative for celiac disease. CT imaging showed a left-sided pericolonic abscess and wall thickening of the lower descending and proximal sigmoid colon. An ill-defined soft tissue density in the left paracolic gutter was also seen and classified as a reactive lymph node. Abscess underwent CT aspiration; follow-up CT noted a new focal area of segmental wall thickening in the ascending colon with an inflamed diverticulum. IBD consult was recommended where negative EGD/colonoscopy resulted in MRI Enterography referral and results suggestive of peritoneal malignancy (Figure). Pathologic examination confirmed the presence of MPM, biphasic type (epithelial/spindle) with cytologic atypia and invasive growth being consistent with malignancy. The patient is on nivolumab, ipilimumab, carboplatin, pemetrexed and leuprolide for the next 3 months and considering debulking. Discussion: MPM presenting with decades long history of LUQ/LLQ pain exacerbations is rarely seen. CT results led to consideration of IBD etiology, as wall thickening, inflamed diverticulum, and a timeline suggestive of IBD was described. The lack of asbestos exposure highlighted the unlikely MPM differential. Prompt advanced imaging was key to diagnosis. Due to the insidious nature of MPM and poor outcomes, further exploration of timely advanced imaging is warranted.Figure 1.: MRI enterography reveals no evidence of active or chronic inflammatory bowel disease and no evidence of diverticulitis or diverticular abscess. There is a 10 mm enhancing nodule along the serosal margin of the splenic flexure in the left upper quadrant that is suspicious for a peritoneal malignancy.

Management of inflamed sigmoid diverticulum inside an incarcerated right inguinal hernia: Case report of a rare discovery.

IntroductionIncarcerated inguinal hernia is one of the most common emergencies in surgery. The diagnosis is usually made by physical examination, but the contents of the hernia sac may vary.Case presentationWe present a rare case of inflamed diverticulum of the sigmoid colon found within an incarcerated right inguinal hernia sac in a 77-year-old man. The inflamed diverticulum was resected, and the hernia was repaired with synthetic mesh. No postoperative complication occurred. No previous study has reported a similar approach.DiscussionIt is most unusual for an uncomplicated inflamed sigmoid colon diverticulum to be found in the hernia sac when performing acute repair of an incarcerated inguinal hernia. Resection of the diverticulum and subsequent repair of the hernia with synthetic mesh is an attractive alternative.ConclusionAcute diverticulitis should always be considered in patients with an acute abdomen, this includes those with a painful hernia. Emergency surgery should not be delayed, and local resection of the inflamed diverticulum may be an option if no perforation is apparent, and the surrounding colon is unaffected.

S1917 Complicated Diverticulitis of the Sigmoid Flexure in a Patient with Left Nephrolithiasis

Introduction: Complicated diverticulitis is defined as diverticular inflammation associated with hemorrhage, abscess, phlegmon, perforation or obstruction. There are currently no reported cases of complicated diverticulitis occurring secondary to obstructive nephrolithiasis. We report a patient admitted for a left ureteral stone, whose significant perinephric inflammation was suspected to play a role in the development of complicated diverticulitis. Case description/methods: A 76 year old woman with history of recurrent nephrolithiasis presented with acute left flank pain. On arrival, she was mildly tachycardic. Physical exam was notable for left costovertebral angle tenderness. Labs were notable for an elevated blood urea nitrogen of 25 mg/dL. Computed tomography (CT) abdomen showed a 6 mm obstructing calculus within the left proximal ureter causing moderate hydronephrosis and significant peri-nephric inflammation. The patient was started on ceftriaxone. The next day, she had a worsening leukocytosis and an acute kidney injury, so she was taken urgently for left ureteral stent placement. Postoperatively, she had significant abdominal pain, so a repeat CT abdomen was obtained. It revealed inflamed diverticulum at the splenic flexure with an associated abscess abutting the spleen, consistent with complicated diverticulitis. She was managed supportively with nasogastric tube decompression, pain control, and broadened antibiotics. On hospital day 8, her abdominal pain worsened. Repeat CT abdomen showed enlargement of the perisplenic abscess and multiple new small abscesses anterior to the spleen. The patient was taken for laparoscopic splenectomy, which was complicated by iatrogenic perforation of the stomach, peritonitis, and septic shock. After a prolonged and complicated hospital stay in the surgical intensive care unit, the patient was discharged to a long term care facility. Discussion: Our patient's complicated diverticulitis was suspected to be secondary to her left ureteral stone. While most cases of diverticulitis occur at the sigmoid colon, our patient’s was at the splenic flexure, in close proximity to the left renal fossa where significant inflammation was noted on initial imaging. It is also possible that her diverticulitis was a consequence of iatrogenic ureteral injury during cystoscopy. Clinicians should be aware that complicated diverticulitis may occur in relation to nephrolithiasis.Figure 1.: a: Synaptophysin positive tumor cells b: Chromogranin A positive tumor cells c: Colonoscopy showing 2 cm mass at Hepatic flexure. d: High grade adenocarcinoma arising in a background of sessile serrated adenoma e: CK7 positive immunohistochemical staining.

Acute Jejenal Diverticulitis: Case Report of Uncommon Presentation

Jejunal diverticulitis is a rare condition and often difficult to diagnose. We report a case of 68-year–old man with a history of sigmoid diverticulitis who presented to the emergency room with a one day history of acute abdominal pain of the left lower quadrant. Initial CT of the Abdomen and Pelvis revealed ileus vs early/partial small bowel obstruction mildly distended loops of the small bowel with decompressed loops of small bowel in the right lower quadrant with no distinct transition point. The patient was treated with antibiotics for presumed gastroenteritis. However, given persistent symptoms and unclear etiology a CT enterography was ordered and demonstrated jejunal diverticulitis with microperforation and a significant phlegmon surrounding the inflamed diverticulum. The patient was treated with ciprofloxacin and metronidazole and reported complete resolution of symptoms after the course of antibiotics. Jejunal diverticula are extremely rare with an incidence of 0.06% to 1.3%. Prior case reports described some of its complications including bleeding, perforation and ulceration. Jejunal diverticulitis should be in the differential diagnosis of acute abdomen especially in patients with unclear etiology. This condition can be missed by contrasted CT of the abdomen and dedicated small bowel imaging such as CT Enterography can assist making the diagnosis.

Acute abdomen in children due to different presentations of complicated Meckel\u2019s diverticulum: a case series

BackgroundMeckel’s diverticulum (MD) is the commonest congenital abnormality of the gastrointestinal tract that occurs in 2% of general population. It remains asymptomatic, but it may lead to life-threatening complications. These complications may be misdiagnosed with other gastrointestinal disorders like acute appendicitis, making its diagnosis challenging among pediatricians and pediatric surgeons. In this study, we reported five cases with different presentations of complicated MD in children.ResultsFive patients with different presentations of MD were reported during the period from January 2016 to January 2020. Patients’ demographics, clinical presentations, investigations, operative data, and postoperative outcome were recorded and analyzed.ConclusionsThe present study highlights different presentations of MD. Surgical interference is the main key of treatment of symptomatic MD either by wedge resection of a small base diverticulum or by resection anastomosis of the small intestine in wide base and inflamed diverticulum.

S2131 Massive Hematochezia From a Large Bleeding Duodenal Diverticulum

INTRODUCTION: Duodenal diverticula are a rare cause of GI bleeding despite being a common finding in the GI tract. We present a case of a patient who had massive hematochezia due to a complex duodenal diverticulum. CASE DESCRIPTION/METHODS: A 74 year old Hispanic female with past medical history of type 2 diabetes mellitus presented with weakness. She denied any aspirin or NSAID use. On admission, vital signs were normal and she had pale conjunctiva. Labs were significant for Hgb 6.7 g/dL and blood glucose of 494 mg/dL. She was admitted for transfusion and glucose management. After admission, she had an episode of large amount of red blood per rectum. She became hypotensive and Hgb dropped to 3.7 g/dL. She was intubated, transferred to the ICU and started on pantoprazole drip. Repeat Hgb was 10.5 g/dL after 4 units of packed RBC. EGD using a forward-viewing endoscope was done which showed a 30 mm diverticulum in the area of the major papilla with multiple smaller diverticula within the main diverticulum. There were several angiodysplasias within the diverticulum that were oozing blood (Figure 1). The lesions were injected with epinephrine and four hemostatic clips were placed (Figure 2). There was no further bleeding after intervention and Hgb remained stable. DISCUSSION: Duodenal diverticula are common findings in the GI tract and the vast majority are asymptomatic. The most common location is the descending part of the duodenum. Duodenal diverticula are a rare cause of GI bleeding. Diverticular bleeding can be due to an inflamed diverticulum, erosion into a major vessel, Dieulafoy lesion, aortoenteric fistula formation or angiodysplasia. EGD is a useful tool in diagnosing bleeding duodenal diverticula, but a side-viewing endoscope may be needed if no bleeding source is identified on forward-viewing endoscopes. Various endoscopic therapeutic strategies such as injection with epinephrine, bipolar coagulation, APC and hemostatic clips have been used for treatment of bleeding duodenal diverticula. In our case, successful hemostasis was achieved with epinephrine injection followed by placement of hemostatic clips. Duodenal diverticula should be included in the consideration of rare causes of hematochezia. Prompt diagnosis and treatment is necessary to avoid life-threatening complications.Figure 1.: Actively oozing angiodysplasias within the diverticulum.Figure 2.: Angiodysplasias after injection and hemostatic clip placement. No bleeding seen post intervention.

1638 Post-Colonoscopy Diverticulitis: A Rare Complication

INTRODUCTION: Post-colonoscopy diverticulitis is a rare but potentially significant complication. We report a case of colonoscopy-induced diverticulitis in a patient with no prior history of diverticulitis. CASE DESCRIPTION/METHODS: A 59-year-old female with a past medical history of hypertension, hypothyroidism and gastroesophageal reflux disease presented for a screening colonoscopy. Colonoscopy findings included a few small and large-mouthed diverticula in the sigmoid colon, a 4mm sessile polyp in the sigmoid colon removed with cold biopsy forceps, and non-bleeding grade I internal hemorrhoids. Pathology of the polyp returned as tubular adenoma. Two days post-procedure, she reported worsening lower abdominal pain as well as nausea and was recommended to go to the emergency room. On arrival, she was afebrile and hemodynamically stable. She was noted to have tenderness to palpation along her lower abdomen, greatest in the left lower quadrant. She denied fevers, chills or rectal bleeding. Labs were significant for a white blood cell count of 11.63 × 103/μL (reference range 4.5-11 × 103/μL). CT abdomen/pelvis with IV contrast showed inflamed diverticulum within the sigmoid colon with surrounding inflammatory changes, consistent with uncomplicated sigmoid diverticulitis. She was discharged home with a 10 day course of ciprofloxacin and metronidazole, and was doing well at her follow up visit. DISCUSSION: Although colonoscopy-induced diverticulitis is a rare finding, it is important to consider it as a complication in patients with symptoms after colonoscopy. Potential causes of post-colonoscopy diverticulitis include barotrauma, multiple attempts for intubation, and direct pressure of the scope. Another possible cause is reactivation of silent diverticulitis, with air insufflation unsealing micro-perforations in diverticula. Prior history of diverticulitis is associated with incomplete colonoscopy and can be a risk factor for developing diverticulitis; this is likely due to deformed colonic architecture from prior severe inflammation. Our patient had no prior history of diverticulitis, and presented with diverticulitis two days after her first colonoscopy. More research needs to be done on the risk of post-colonoscopy diverticulitis in those without a prior history of diverticulitis, as the prevalence of this complication is likely higher than reported.

Vertebral erosion due to chronic rupture of aneurismatic abdominal aorta

Introduction. Extremely rarely, the evolution of abdominal aortic aneurysm (AAA) includes the phase when extravasations of the blood from a ruptured aneurysm is contained by the surrounding tissue, referred to as chronic (contained) rupture of the AAA. Our aim was to call attention to this life-threatening condition, which is always challenging for diagnosis. Case outline. A 58-year-old man reported to the Emergency Center for significant abdominal pain. Ultrasound examination showed an infrarenal aneurysm of the abdominal aorta. A computed tomography scan of the thorax, abdomen, and pelvis with iodine contrast in arterial phase was performed. A free gas collection was observed between the liver and the anterior abdominal wall that is traced to a ruptured inflamed diverticulum on the transversal colon. Immediately distal to the branching sites of the renal arteries, the abdominal aorta extended forward and aneurismatically expanded. Posterior left, along the psoas muscle, a rupture of the aortic wall was seen, with an organized hematoma that accompanied the muscle. Between the hematoma and the aortic aneurysm, erosions of the anterior and lateral part of the vertebral bodies L2 and L3 were discovered. The patient underwent endovascular AAA repair (EVAR) and recovered well. Conclusion. Multidetector computed tomography angiography is a reliable, non-invasive, and necessary examination for localization and evaluation of the size of the AAA form, its chronic rupture, and complications such as vertebral body erosion.

Diverticulitis: An atypical presentation

Introduction Diverticulitis is a well described inflammatory condition of the wall of the gastrointestinal tract with an overall prevalence of 2-10% in developing countries. Typically, the descending and sigmoid colon are affected more commonly than the ascending colon and small bowel in the Western population. Diverticula of the distal ileum are particularly uncommon, with a reported rate of 0.06-1.3% (Jeong et al. 2014). Due to difficulty in pre-operative diagnosis, there is no consensus on therapeutic strategy for right-sided diverticulitis (Lee et al. 2010). Here, the authors present a case of non-Meckel’s diverticulitis of the distal ileum in a Caucasian U.K. patient. Case description A 63 year old man presented to the Emergency Department with a one day history of abdominal distension, periumbilical pain radiating to the right iliac fossa, nausea and sweats. He had not defecated for 2 days but reported passing flatus. Past medical history included gout, rheumatoid arthritis and Ulcerative Colitis, managed with Sulfasalazine. He was not a smoker. On examination, abdomen was visibly distended. There was maximal tenderness in the lower central abdomen and guarding to palpation. Digital rectal examination was normal. Chest radiograph was unremarkable. Plain abdominal film showed faecal loading of the colon, but no obstructive features. C-Reactive Protein (CRP), amylase and white cell count on admission were normal. On repeat testing, CRP was 208mg/L, white cell count 10x10 9 /L, venous lactate 2.3mmol/L and haemoglobin 13.1g/L. Intravenous fluids and broad spectrum antibiotics were commenced. CT imaging was arranged in view of the severity of symptoms, biochemical findings, patient’s age, medication and history of colitis. CT abdomen pelvis with oral contrast showed a severely inflamed ileal diverticulum. There was no suggestion of a diverticulum on previous radiological or endoscopic investigations. The patient proceeded to surgery for open resection of perforated diverticulum (39cm of ileum) and small bowel anastomosis. Results and Conclusions After 24 hour High Dependency observation, the patient made an uneventful recovery. Histological analysis confirmed a thin-walled, diffusely ulcerated, perforated ileal diverticulum resulting from obstructing food. Anatomically, diverticula are characterised by herniation of mucosa and submucosa through the muscular bowel wall and a true diverticulum should involve all layers. Diverticula of the small bowel are more commonly proximal (75% jejunal, versus 5% ileal). The position, conversely to a Meckel’s diverticulum, is usually on the mesenteric side of the bowel. The aetiology of jejuneo-ileal diverticula is not fully understood however focal muscular weakness, motility dysfunction, high segmental intraluminal pressure and biogenetic factors are believed to contribute (Nakatani et al. 2016). There is close clinical and biochemical overlap between a presentation of appendicitis and right sided diverticulitis. However, previous studies have suggested subtle clinical variations to aid their distinction, such as duration of onset, location or migration of pain and severity of systemic response (Lee et al. 2010). The use of ultrasonography and CT to aid diagnosis has been advocated, which may show bowel wall thickening, peri-colonic fat infiltration, extra-luminal air or abscess. Compared to duodenal, small bowel diverticula are almost 4 times more likely to perforate (Nakatani et al. 2016). Take home message Although less common than appendicitis, diverticulitis of the ascending colon or terminal ileum should be considered in patients presenting with right iliac fossa pain. Limited small bowel resection and anastomosis or diverticulectomy is a safe surgical method to use in some cases of ileal diverticulitis. Many cases of uncomplicated small bowel diverticulitis may be treated conservatively without requiring operative intervention. Thus accurate and early diagnosis, aided by radiological imaging can ensure appropriate clinical management and avoid unnecessary surgery and its associated risks for patients presenting with acute, uncomplicated small bowel diverticulitis.

CT Predictors of Unfavorable Clinical Outcomes of Acute Right Colonic Diverticulitis.

The purpose of this study was to retrospectively assess CT predictors of unfavorable outcomes of medical treatment in patients with right colonic diverticulitis. Of 394 patients with right colonic diverticulitis diagnosed on the basis of CT findings from January 2010 through August 2013, we included 328 (190 men, 138 women; mean age, 41.3 ± 12.6 years) who had undergone medical treatment as inpatients. Two radiologists retrospectively reviewed the following CT findings associated with diverticulitis: number of diverticula per 10 cm of colon; length and thickness of affected colonic wall; diameter of inflamed diverticulum and abscess; presence of pericolic fluid collection, spilled feces, and contained air; and extent of fatty infiltration. Logistic regression analysis and the Cox proportional hazards regression model were used to determine significant variables predictive of unfavorable outcomes, including surgery after failed medical treatment, recurrence, and prolonged hospital stay. Of the 328 patients, nine underwent surgery after failed medical treatment. Of the other 319 patients, 35 had recurrence and 49 had a prolonged hospital stay. The spilled feces sign (adjusted odds ratio [OR], 111; p < 0.001) and serum WBC count (adjusted OR, 1.3; p = 0.047) were independent predictors of the need for surgery. More than five multiple diverticula per 10 cm of colon was significantly associated with recurrence (adjusted hazard ratio, 4.1; p < 0.001). Abscess larger than 4 cm (adjusted OR, 18.2; p = 0.01) and inflamed diverticulum larger than 2 cm (adjusted OR, 3.7; p = 0.001) were independent predictors of prolonged hospital stay. Some specific CT findings can be useful predictors of unfavorable clinical outcomes of right colonic diverticulitis.

Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations.

Appendiceal diverticulitis is relatively rare and is difficult to distinguish clinically and radiologically from acute appendicitis. The aim of this study was to describe the computed tomography (CT) findings of acute appendiceal diverticulitis. Among the 1329 patients who underwent appendectomy at our institution between January 2010 and July 2015, 28 were diagnosed pathologically with appendiceal diverticulitis, including 24 patients who were evaluated by preoperative CT. The control group consisted of 38 patients without diverticulitis. Average age of patients, ratio of males to females, appendiceal diameter, presence of a diverticulum, diverticular enhancement, peri-appendiceal fat stranding, peri-appendiceal loculated fluid and perforation, and the presence of appendicolith were evaluated retrospectively. Peri-appendiceal fat stranding (p<0.005), appendiceal diameter (p<0.005), and peri-appendiceal loculated fluid differed significantly between the diverticulitis and non-diverticulitis groups (p<0.005). Although relatively uncommon, appendiceal diverticulitis should be included in the differential diagnosis of acute appendicitis. It differs from typical acute appendicitis by the presence of an inflamed diverticulum, seen on CT. These patients are also more likely to have peri-appendiceal extra-luminal loculated fluid, peri-appendiceal fat stranding, and a larger diameter of the appendix. The latter finding is likely due to the increased intraluminal pressure.

A liver nodule in a patient transplanted for primary sclerosing cholangitis: an interdisciplinary diagnostic approach.

We report the case of a 53-year-old female patient who was transplanted with the liver of a 71-year-old male donor for advanced primary sclerosing cholangitis (PSC) and who additionally was diagnosed with a histologically non-classifiable colitis shortly before transplantation. Upon follow-up abdominal ultrasound 4 months after transplantation, a liver lesion measuring 16 × 23 mm was detected in the transplanted liver. This lesion had not been noticed immediately after transplantation and showed a pattern suspicious for malignancy in contrast-enhanced ultrasound. In line, a biopsy revealed the presence of a metastasis of an adenocarcinoma of colorectal origin, suggesting that a colitis- and PSC-associated colorectal cancer of the recipient might have been overseen upon the initial diagnostic workup. Despite two negative follow-up colonoscopies, this hypothesis was further supported by a strong positive signal in projection to the cecum in a subsequently performed PET/CT-scan. However, surgical resection of the right colon that was performed simultaneously with the atypical resection of the liver metastasis only revealed an inflamed diverticulum but no malignancy in the resected colon segment. Moreover, cytogenetic and molecular genetic testing on the resected specimens clearly attributed the metastasis to the male donor. On the one hand, this case underlines the necessity of endoscopic surveillance of patients with PSC and/or inflammatory bowel disease as well as the challenges in diagnosis of colitis-associated cancer. On the other hand, it shows that the acceptance of organs from elderly donors in times of organ shortage might be linked to an increased risk of donor transmitted malignancies.

Diagnostic and Therapeutic Value of Diagnostic Laparoscopy in Patient with Chronic Abdominal Pain

Chronic abdominal pain is a troublesome dilemma confronting both the medical and surgical care professionals. These patients are submitted to a lot of diagnostic investigations but no precise etiology of their problem could be elucidated. Diagnostic laparoscopy, apart from visualizing the entire abdominal cavity, allows us to take precise biopsies. Laparoscopy also offers a therapeutic solution for many causes of chronic abdominal pain. Methods : Patient with the inclusion criteria underwent diagnostic laparoscopy for chronic abdominal pain over the last three years from January 2011 to December 2013. The patient’s demographic data, duration of abdominal pain, diagnostic studies, intra-operative findings, interventions and follow-up results were recorded. Results : In this study, 80 patients with an average age of 23 ±14.76 years underwent diagnostic laparoscopy for the evaluation and treatment of chronic abdominal pain. The average duration of pain was 8± 2.85 months. Findings included intra-abdominal tuberculousis in 4 patients, internal herniation in 2 patients, significant intra-abdominal adhesions in 18 patients, secondary intessusception in 2 patients, abdominal lymphadenopathy due to lymphoma in 2 patients, cecal diverticulum in 2 patients and subacute appendicitis in 19 patients, Chron's disease in 2 patients, endometriosis in 3 patients and inflamed Meckle's diverticulum in 1 patient. Conclusion : Diagnostic laparoscopy is an effective and safe diagnostic and therapeutic tool in evaluating patients with chronic abdominal pain.

Study of role of laparoscopy in acute abdomen

Study regarding role of laparoscopy in acute abdomen was conducted at Shree Chhatrapati Shivaji Maharaj Sarvopachar Rugnalaya, Solapur during the period from May 2004 to November 2006. Patients of both sex and all age groups were included in the study. A total 30 patients were studied and results were as tabulated and analysed. In this study, total laparoscopic management was possible in 23 cases (76.7%) while laparoscopy assisted surgery were done in 4 cases (13.3%). In this study, 5 cases presented as adhesive small bowel obstruction, 1 with inflamed Meckels diverticulum and 1 as case of ileoileal intussusception. All these findings were missed on radiological investigations, but was diagnosed accurately on laparoscopy. Laparoscopic tratment was done in 9 cases presented as acute abdomen due to intestinal obstruction. This incidence is equal to that of acute cholecystitis. Of these, 5 patients (55.6%) were due to post operative adhesions.We conclude that laparoscopy is valuable, safe feasible and accurate alternative for management of patients of acute abdomen. It is very useful for final diagnosis of patients of acute abdomen. Even negative laparotomies can be avoided using laparoscopy. Therapeutic laparoscopy can be accomplished in majority of patients of acute abdomen.

Diagnostic and Therapeutic Value of Diagnostic Laparoscopy in Patient with Chronic Abdominal Pain

Introduction: Chronic abdominal pain is a troublesome dilemma confronting both the medical and surgical care professionals. These patients are submitted to a lot of diagnostic investigations but, regretfully, no precise etiology of their problem could be elucidated. Diagnostic laparoscopy, apart from visualizing the entire abdominal cavity, allows us to take precise biopsies. Laparoscopy also offers a therapeutic solution for many causes of chronic abdominal pain. Patient and Methods: Patient with the inclusion criteria underwent diagnostic laparoscopy for chronic abdominal pain over the last three years from January 2011 to December 2013. The patient’s demographic data, duration of abdominal pain, diagnostic studies, intra-operative findings, interventions and follow-up results were recorded. Results: In this study, 80 patients (55 female and 25male) with an average age of 23 ± 14.76 years underwent diagnostic laparoscopy for the evaluation and treatment of chronic abdominal pain. The average duration of pain was 8 ± 2.85 months. Findings included intra-abdominal tuberculousis in 4 patients, internal herniation in 2 patients, significant intra-abdominal adhesions in 18 patients, secondary intessusception in 2 patients, small intestinal stone in 1 patient, intestinal lymphoma in 1 patient, abdominal lymphadenopathy due to lymphoma in 2 patients, cecal diverticulum in 2 patients and subacute appendicitis in 19 patients, jejunal diverticulum in 1 patient, Chron's disease in 2 patients, endometriosis in 3 patients and inflamed Meckle's diverticulum in 1 patient. Conclusion: Diagnostic laparoscopy is a simple, rapid, effective and accurate tool in evaluating patients with chronic abdominal pain, in whom conventional methods of investigations have failed to elicit a certain cause with the advantage that it is an effective therapeutic and accessible tissue sampling tool.

Right Upper Quadrant Pain in a 21-Year-Old Man

Question: A 21-year-old man with attention deficit hyperactivity disorder developed acute-onset, severe, right upper quadrant pain shortly after being taken into police custody. He volunteered no further past medical history or gastrointestinal symptoms other than pain. On examination, vital signs were: Heart rate, 68; blood pressure, 110/74 mmHg; temperature 37.5°C; respiratory rate, 14; and SpO2, 97% on room air. There was generalized guarding with marked rebound tenderness maximally in the right upper quadrant; electrocardiograph showed normal sinus rhythm and erect chest x-ray did not demonstrate a pneumoperitoneum. Bloods included: Hemoglobin, 16.3 g/dL; white cell count, 6.8 × 109/L; urea, 2.8 mmol/L; creatinine, 71 μmol/L; bilirubin, 17 μg/L; alkaline phosphatase, 65 U/L; alanine transferase, 10 U/L; and C-reactive protein, 48 mg/L; all other blood results were unremarkable. A provisional diagnosis of an acute appendicitis was made and he was taken to the operating room without further imaging, where the following was found (Figure A, B). What is the diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. On laparoscopy, a classical mid-gut malrotation was found with a centrally positioned caecum. In addition, a large Meckel's diverticulum was seen arising from the ileum behind Ladd's bands in the right upper quadrant (Figure A). On open conversion, Ladd's bands were divided and the gut mobilized to the anatomical position. Given the broad-based diverticulum, small bowel resection with end-to-end anastomosis was performed, together with cecopexy and appendectomy. Histologic examination revealed Meckel's diverticulitis with areas of ectopic duodenal mucosa (Figure B) and minor regenerative changes throughout adjacent small bowel. Later, on gaining a collateral history, it transpired that he had a lifelong record of hospital admissions for abdominal complaints for which no cause had been identified. Intestinal malrotation is a congenital anomaly affecting 1 in 500 births1Torres A.M. Ziegler M.M. Malrotation of the intestine.World J Surg. 1993; 17: 326-331Crossref PubMed Scopus (191) Google Scholar and arises as a deviation from the normal 270° counterclockwise rotation of the gut during embryogenesis. Overall, 80% present in the neonatal period,2Von Flue M. Herzog U. Ackermann C. et al.Acute and chronic presentation of intestinal nonrotation in adults.Dis Colon Rectum. 1994; 37: 192-198Crossref PubMed Scopus (108) Google Scholar although some remain undetected until adulthood when they may develop obstruction owing to volvulus or internal herniation. Others are found incidentally or after imaging for intermittent abdominal pain, which may represent episodes of spontaneously resolving subacute obstruction. In this case, because the bowel appeared grossly normal, symptoms were attributed to the Meckel's diverticulum. These 2 mid-gut abnormalities are not classically associated and indeed it is difficult to determine whether the malrotation was an incidental finding in this case. If so, the inflamed diverticulum may have been a serendipitous occurrence given that surgical correction of malrotation is the only prophylaxis against future catastrophic complications. This case demonstrates that serious underlying pathology cannot be reliably ruled out by routine admission investigations, highlighting the importance of clinical intuition in the absence of objective evidence. Furthermore, of the reported cases of intestinal malrotation presenting acutely in adult life, many are associated with a long history of nonspecific pain, emphasizing the need for thorough investigation of chronic pain beginning in childhood, regardless of distracting behavioral or psychiatric issues.

Solitary cecal diverticulitis: an unusual cause of acute right iliac fossa pain-a case report and review of the literature.

Solitary cecal diverticulitis is a rare cause of acute abdominal pain in the Western world. Its clinical presentation, in most cases, mimics acute appendicitis. A 38-year-old Caucasian man presented with acute abdomen and clinical signs of acute appendicitis. Laparotomy was performed and revealed an inflammatory, solitary diverticulum of the cecum. A typical appendectomy was performed and a catheter was inserted for draining percutaneously the inflamed diverticulum of the cecum. The patient had an uneventful recovery and was discharged on the 4th postoperative day. This frequently misdiagnosed condition, in most cases, is being suspected and identified intraoperatively as acute appendicitis. The aim of this study is to review the available different surgical management options and to present an alternative therapeutic approach that may be valuable under specific circumstances.