Gastro 51 Colon and rectum - Diverticulum Volvulus Pseudoobstruction

Mesenteric side of antimesenteric tenia coli is area of relatively weakness in the bowel, where small arterioles (vasa recta) penetrate the muscular layer as they traverse colon wall. Diverticula donot form in antimesenteric side.

Perforation of colonic diverticulum, which leads to pericolic inflammation as there is extravasation of feculent fluid through the ruptured diverticula.

• Abscess
• Fistula – Bladder, vagina, skin
• Obstruction – due to stricture, rule out malignancy
• Free perforation

Antibiotics, Dietary modification, for recurrent cases – surgery (required in only 1% of cases) – removal of affected colon and end to end primary anastomosis.

• Stage I – Small, confined pericolic or mesenteric abscess
• Stage II – Large, walled off pelvic abscess
• Stage III – Generalized purulent peritonitis
• Stage IV – Generalized fecal peritonitis

• I and II – Percutaneous drainage, IV antibiotics, Elective resection of involved segment and primary anastomosis
• III and IV – a) Immediate surgical exploration, Hartmans procedure b) Laparoscopic lavage, placement of drain – those who fail – colectomy. Successful laparoscopic lavage may obviate need of elective resection.

• The dome of the bladder is the most common site of fistulas, but the vagina and small bowel are also
• notable sites.
• Patients with colovesical fistulas will frequently present with recurrent urinary tract infections
• but may also report pneumaturia or fecaluria.
• Initial treatment includes broad-spectrum antibiotics to ensure resolution of the inflammation. A colonoscopy to examine the affected colon and to exclude colon cancer or Crohn’s disease as the cause of the fistula is important for preoperative planning.
• Elective resection of the involved colon and fistula tract should then be performed with subsequent primary anastomosis. If a small defect is encountered in the bladder, it may not be necessary to close this primarily, as healing will occur spontaneously if the bladder is drained with a Foley catheter for 7 days after the operation.
• Larger defects will require primary closure with absorbable sutures combined with Foley drainage. Fistulas to the small bowel will typically require resection and primary anastomosis.

• Rule out malignancy
• NG tube
• Drainage of abscess
• IV antibiotics

Diverticula in young (<50yrs) in considered more virulent with worse clinical outcome and higher recurrent rate – elective resection , even in uncomplicated diseases

Bowel twist on its mesenteric axis that results in partial or complete obstruction of bowel lumen and a variable degree of impairment of blood supply.

• Sigmoid colon
• Cecaum
• Transverse colon

Mesenteric whorl in CECT, Bird’s beak appearance in barium enema

• Rectal tube – if successful, place for 1-2 days, plan for elective resection. If comorbid – plan endoscopic colopexy
• If failed, Hartman procedure

Cecum folds in the cephaloid direction anteriorly over the fixed ascending colon. (bascule – a type of bridge with section which can be raised and lowered using counter weight)

Axial rotation of terminal ileum, cecum and ascending colon. Treat with right colectomy.

Strangulated hernia, volvulus, colonic cancer occluding the lumen in the presence of competent IC valve.

Pseudoobstruction, no physical obstruction

• 1. Primary Pseudoobstruciton – a) Familial visceral myopathy (hollow visceral myopathy syndrome) b) Diffuse motility disorder involving the autonomic innervation of intestinal wall
• 2. Secondary Pseudoobstruciton – Neuroleptic medications, opiates, severe metabolic illness, myxedema, DM, Uremia, parikinsons disease, traumatic retroperitoneal hematoma

Sympathetic overactivity overriding the parasympathetic system. Evidence for this pathogenesis a) Resolution of symptoms after administration of epidural anesthesia that provides sympathetic blockage b) Neostigmine - 2.5mg over 3 minutes

Sympathetic inhibition: Guanethidine 20 mg (2 amps) in 500 ml 5% dextrose in water is given over 1 hour intravenously. If no bowel action results within 1/2 hour of the onset of this infusion then:

Parasympathetic stimulation: Prostigmine (Neostigmine) - 2.5 mg IV over 3 minute

Bradycardia. Atrophine should be in bedside before giving neostigmine.

How to diagnose a case of sigmoid volvulus. Discuss the management of sigmoid volvulus 72/6