M

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M M Conference

• Yassar Youssef
• July 25th, 2006

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General Information

• Patients name G.M.
• MR 11260764
• Attending Dr. Baxt
• Reason for admission Complicated diverticulitis
• Morbidity PE, Bleeding, ICU admission

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Mr. G.M. MR 11260764

• 66 y.o. Caucasian male
• Admitted on July 2nd for sepsis
• Hx of diverticulosis that was complicated by an
  acute attack of diverticulitis and fistulization
• Antibiotics, hydration, steroid and surgical
  consults

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Past History

• Chronic severe asthma (gt 30 year)
• Aortic aneurysm
• HTN
• Chronic steroid use with 2nd adrenal
  insufficiency
• Hyperlipidemia
• Smoke till age 26 4 beer / day

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Medications

• Singulair
• Celebrex
• Albuterol
• Hydrocodon
• Crestor
• Zetia
• Prednisone 10 mg daily

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PE

• T 38 BP 104/66 HR 80
• Heart and lung Nl
• Abdomen soft with no guarding or rebound
• Urinary symptoms with culture Enterococcus
  group D Greater than 100,000 Cfu/ml
• Blood culture E. Coli

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CT scan
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Operation (10th)

• Exploratory Laparotomy
• Sigmoidectomy
• Resection of colo-vesical fistulae
• Primary repair of the bladder (folley)
• Attempts of primary anastomosis
• End colostomy

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Pathology

• Active diverticulitis with associated fistula
• Unremarkable LN
• No malignancy

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Post-op course

• Did well until day 3 post-op
• Sudden shortness of breath and tachycardia
• Work up with cardiac enzymes, CXR and labs
• Treatment for asthma
• A chest CT with IV contrast was performed

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Venous Duplex Scan
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Post-op course

• The patient was started on heparin and taken to
  the intensive care unit
• An IVC filter was placed.
• The PTT rose dramatically. The patient had
  medical consult at that time and was diagnosed as
  being in delirium. CT of the head ruled out any
  type of infarct or bleed

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Post-op course

• On 07/18/2006 the patient's PTT once again rose
• Anticoagulations were stopped
• Hematocrit droped to 19.4 and he was given
  multiple blood transfusions
• Admitted to the ICU
• Was started slowly on Coumadin 2 mg

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Post-op course
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Discharge

• Repeat CT scan of chest
• Stable
• Disharged on 07/21 with
• Folley
• Coumadin 2 mg
• Asthma medications
• Steroid

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Fistula and Diverticulitis

• Fairly frequent (5) with colovesical 65 (2nd
  after mass/abscess)
• Diagnosis can be difficult
• Cystoscopy, CT scan with symptoms, Barium enema
• Colovaginal 2nd most common (hysterectomy)
• Cancer ? (endoscopy!)
• Can do primary anastomosis (omentum)

Fistula in complicating diverticulitis, Int J
colorectal Dis 1998
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Colon Surgery and DVT

• Higher risk for DVT than other abdominal
  surgeries
• Incidence 30 (with no prophylaxis) (as high as
  40)
• Prophylaxis is very effective (60-70)

1- Results of the Canadian colorectal DVT
prophylaxis trial a randomized, double-blind
trial, Ann Surg (2001) 2- Systematic review of
thromboprophylaxis in colorectal surgeryan
update, Colorectal Dis 7 (2005)
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Colon Surgery and DVT

• LMWH or LDUH
• No major explanation, could be
• need for pelvic dissection
• patient positioning (stirrups)
• IBD and Cancer
• Preventive measures are frequently NOT used

1- Results of the Canadian colorectal DVT
prophylaxis trial a randomized, double-blind
trial, Ann Surg (2001) 2- Systematic review of
thromboprophylaxis in colorectal surgeryan
update, Colorectal Dis 7 (2005)
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Isolated calf vein thrombosis

• Do not cause major sequelae
• Low risk for fatal PE
• Propagate to large proximal veins (30)
• High risk of post-thrombotic complications

Isolated deep venous thrombosis J Vasc Surg, 2002
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Aorto-caval fistula?
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What could we have done different ?

• Prophylactic LMWH
• Wait till the inflammation subsides
• Checking the stirrups
• Decrease OR time (not attempting the primary
  anastomosis)