Surgery Case Presentation
By: Jennifer Distinti PA-S
Presented to: Prof. Acevedo
Chief Complaint:
“
I have been bleeding heavy
from below for about 5 days”.
History of Present Illness:

A 73 year old female with a PMH of
HTN, diverticulosis, and colon polyps
presented to the SBH ER on 10/20/00
at 10:00 p.m.with a c/o of painless
rectal bleeding starting 5 days ago, on
and off. Patient stated that her clothes
were soaked with blood. She admitted
to noticing bright red blood in her stool.
Continued...
h/o dizziness, lethargy, and
lightheadedness
 No h/o abdominal pain
 No nausea or vomiting
 No h/o SOB, CP, palpitations

Past Medical History:
HTN
 1999- Diverticulosis- no surgical Tx.
 1993- Polyps, bleeding- received blood
transfusion.
 No PSH

Other Information:
Allergies:
 None
Family History:
 None
Medications:
 Not known at this
time
Social History:
 Non smoker
 No alcohol use
 No drug use
Physical Exam in ER:
Vitals:
 BP: 121/60
 Pulse: 65
 RR: 18
 Temp: 97
General:
 AOx3 NAD
Skin:
 Clear/no rashes
HEENT:
 No abn. findings
Thyroid:
 Not enlarged on
palpation
Lungs:
 CTABL no w/r/r
Cardiac:
 S1S2 r/r/r
Physical Exam Continued:
Abdomen:
 Soft on palpation
 No masses
 No organomegaly
 + BS on ascultation
Rectal:
 Melena
 Hematachezia
Extremities:
 No edema/calf pain
Laboratory Results in ER:
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H&H: 6.7/19.1
PT: 11.8
INR: 0.99
PTT: 22.8
Lipase: 121
Amylase: 81
Sodium: 139
Potassium: 4.2

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Chloride: 105
Bicarbonate: 22
BUN: 33
Creatinine: 1.1
Glucose: 170
Assessment & Plan:
R/O diverticulosis
 R/O polyps
 NPO
 Monitor vitals
 IVF D5% NS 50 cc/hr
 PRBC
 Tagament 300mg IV q 8 hrs.
 Monitor labs. (H&H)
 Consult GI: sigmoidoscopy/colonoscopy

Anatomy of the Colon:
Anatomy of The Colon:

The colon averages 180cm
– Ascending: 8 inches
– Descending: 12 inches
– Transverse: 18 inches
– Sigmoid: 18 inches
– The cecum is the first portion of the large
bowel and it joins to the small bowel.
Parts of the Right & Left Colon
as Well as there Blood Supply:

Right Colon: --->Superior Mesenteric Artery
–
–
–
–

Cecum
Ascending--->Rt. Colonic Artery
Hepatic Flexure--->Middle Colonic Artery
Proximal Transverse Colon--->Middle Colonic Artery
Left Colon: --->Inferior Mesenteric Artery
–
–
–
–
–
Distal Transverse Colon--->Lt. Colonic Artery
Splenic Flexure
Descending Colon--->Lt. Colonic Artery
Sigmoid Colon--->Sigmoid Artery
Rectosigmoid
Lower Endoscopy Report:

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Indication for procedure: Hematochezia
Level of insertion: up to cecum; colon
180cm.
Findings: diverticulosis from the proximal
descending to proximal transverse colon. Full
diverticulosis in ascending colon with blood
clots. But no active bleeding. Internal
hemorrhoids found as well as colonic polyps
in distal ascending colon.
Continued...
Impression & Dx: Diverticulosis from the
splenic flexure to proximal transverse with
blood clots but no active bleeding. Internal
hemorrhoids found as well.
 Recommendation:
1. Surgery on 10/24/00 for subtotal
colectomy.
2. Monitor CBC
3. Post Op - high fiber/lactose free diet.

Surgical Procedure Used:
(However anastamosis was of the ileum
not the colon to the rectum)
Surgical Procedure Used:
Surgical Procedure Used:

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The procedure is done under general anesthesia.
An incision is made in the abdomen. The incision is
carried through the wall of the abdomen to expose the
bowel.
The diseased portion of the colon is identified and that
portion of the colon and it’s blood supply is divided and
removed.
A stapler placed across the colon seals the colon on each
side of the stapler and then cuts the colon between the
stables. Then the small bowel is joined (anastamosis) to
the rectum using a specific instrument. After the surgery
the abdominal wound was closed with staples.
Postoperative Status:

Postop this patient did very well. She had no physical
complaints of abdominal pain of tenderness on exam.
She had + BS and she was having loose stools which
was expected. Her vitals remained stable and she was
in good spirit. The rest of her physical exam was
normal. The incision had no signs of erythema, edema,
infection or discharge and we removed the staples on
post op day #8. She was put on a low residue/lactose
free diet. PT was call to start the patient ambulating
and depending on her H&H and whether or not blood
was found in her stool, she would be discharged on
11/03/00, which she was.
Diverticulosis:


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It is a condition that is common in Western society.
It increases with age & it is present in approx. 75%
of Americans over age 80.
It is associated with diverticula, which are
protrusions of the innermost lining of the colon
through the muscular outer layer of the colon wall.
The diverticula can become inflamed, a condition
called diverticulitis which can cause perforation of a
bowel abscess, bleeding, obstruction of the bowel or
fistulae of the colon.
Pathophysiology:

A decrease in fiber in the diet is associated with a
high incidence of diverticulosis in Western
population.
– One thought is that when circular muscular contractions
occur in pts. with small amounts of stool in the colon, the
colon lumen becomes occluded.
– When two contractions occur close to one another the
lumen of the intervening segment of the colon is isolated
from the rest of the colon and high pressure is generated
in that segment.
– Increased pressure results in the formation of diverticula
by placing increased tension on the colon wall.
Symptoms and Complications of
Diverticulosis:
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Bleeding (usually right sided)may be massive
Diverticulitis(LLQ pain which is cramping or
steady, change in bowel habits, fever, chills,
anorexia, nausea, vomiting and dysuria)
Asymptomatic (80%) usually diagnosed
incidentally on endoscopy or BE.
Diagnosis of Diverticulosis:

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Usually incidentally during a barium x-ray.
Evaluation of older patients with recent onset
of bowel disturbances should include:
–
–
–
–
Occult blood
CBC
Sigmoidoscopy
Barium enema or colonoscopy
ypocsonoloC
Differential Diagnosis of Lower
GI Hemorrhage:
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Colonic diverticular Dz.
Colonic vascular ectasias
Small intestinal diverticular Dz. (Meckels diverticulum,
pseudodiverticula).
Inflammatory bowel Dz. (Chronic Ulcerative Colitis,
Crohn’s Dz.).
Colonic Neplasms
Small intestinal neoplasms
Angiodysplasia
Aorticenteric fistulae
Colitis (infection, ischemia, radiation induced).
Internal Hemorrhoidal Dz.
Treatments of Diverticulosis:
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Treatment depends on the severity and location of the
diverticulosis, as well as the status of the patient.
A high fiber diet is recommended
Broad spectrum antibiotics if asymptomatic
Examples of surgical procedures used are:
– colostomy
– iliostomy
– right or left hemicolectomy
– subtotal colectomy with anastamosis
Continued:

The indications to operate on a patient with
diverticulosis are:
– complications of diverticulitis (abscess,
fistula, obstruction, stricture).
– Recurrent episodes of diverticulitis
– Hemorrhage
– Suspected carcinoma
– Prolonged symptoms
– ischemic colon
– toxic megacolon
Complications of Colon
Surgery:
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Postoperative bleeding
Dehiscence or breakdown of the anastomosis
Recurrence of a tumor
Wound infection
Urinary or respiratory infection
DVT with or without PE
Urinary retention
Adhesions with bowel obstruction
Obstruction at the anastomosis site
THE END