Is my appendix on the

"right" side?
Delphina Vernor
Surgical Consult

● 64 year old white female admitted with a 10-

day history of worsening severe abdominal
pain and a fever of 38.80C.
HPI
● Pain
○ Crescendo in LLQ for 10 days
○ Unrelieved by passing flatus
○ No Hx of similar pain
○ No radiation
○ Worsened by coughing & sneezing
● Fever
○ Onset 2 days before admission
○ Pt had chills 1 day ago
● Pertinent negative findings
○ Pt denies melena, constipation, obstipation, weight
loss, diarrhea or previous abdominal disease
History
PMHx:
● No Hx of abdominal disease

PSHx:
● Appendectomy 20 years prior

ROS:
● Non-contributory
Vital Signs
Temperature: 38.80C
Blood Pressure: 130/75 mmHg
Pulse: 108/min
RR: 16
DDx
1. Gastroenteritis
2. Nephrolithiasis
3. Ovarian torsion
4. Foreign Body Perforation
5. Diverticulitis
6. Perforated Colon Cancer
7. Appendicitis (r/o in this pt)
Work Up
WBC: 15000/mm3 with left shift
Hct: 43%
Amylase: 81 IU/L
UA: 1-2 WBC/HPF

Abdominal X-Ray: non-specific findings

Initial Treatment Plan
The patient is diagnosed with Diverticulitis.

● NPO

● IV hydration & IV Antibiotics initiated

Anatomy of Large Bowel
● 1.5m or 5 ' long
● separated into:
a. Cecum: dead-end pouch at the beginning, just below
the ileocecal valve
b. appendix:average 10cm(3") long, finger-like
attachment to the cecum that contains lymphoid
tissue and serves immunity functions
c. colon: further divided into ascending, transverse,
descending & sigmoid colon
Anatomy of Large Bowel
Rectum: last 20cm(8")
● mucosa forms longitudinal folds called anal
columns

Anal Canal: last 3cm (1") of rectum

● opens to exterior at anus
● An involuntary (smooth) muscle, the interior
anal sphincter, and a voluntary (skeletal)
muscle, the external anal sphincter, control
the release of the feces through the anus.
Histology
Similar to GI tract:
1. Mucosa: columnar epithelium with mucus
secreting goblet cells, lamina propria &
muscularis mucosa
2. Submucosa: with blood vessels & Meissner
nerve plexus
3. Muscularis propria: inner circular, outer
longitudinal muscles (teniae coli) & Auerbach
nerve plexus.
4. Serosa: visceral peritoneum
Blood Supply
Superior mesenteric artery branches:
● Ileocolic-cecal & appendicular branches
● Right colic
● Middle colic
● Left colic
● Multiple sigmoid arteries
● Superior rectal artery
Blood Suppy & Venous Drainage
Functions of Large Bowel

● Peristalsis
● Bacterial digestion
● Absorption
● Defecation
Definitions
Diverticula: small pouches created by
herniation of mucosa into the wall of the colon
through the intestinal layers and smooth
muscle. They are
false pulsion diverticula

Diverticulosis: condition of having uninflammed

diverticula (associated with low fiber diet,
constipation and obesity)
Signs & Symptoms
● Depends on
○ location of affected diverticulum
○ severity of inflammatory process
○ presence of complications

● Presenting complaints include:

○ LLQ pain (70% of patients)
○ Alterations in bowel habits
■ constipation/diarrhea
○ Nausea & vomiting
○ Flatulence & bloating
Physical Findings
1. Simple diverticulitis
● localized abdominal tenderness in the
affected area. Constant pain that
increases daily before fever onset
● fever
● LLQ is most common: most diverticula
occur in sigmoid colon
● RLQ mimics acute appendicitis
Physical Findings
2. Complicated diverticulitis:
● abscess formation
● tender palpable mass

NB: GI bleeding associated with diverticulosis

(55%) but not usually diverticulitis.

Note: Elderly patients and patients taking

corticosteroids may be asymptomatic even with
severe disease
Physical Findings:
Pts with peritonitis due to perforation:
● generalized tenderness with rebound &
guarding
● distention and tympany on percussion
● diminished/absent bowel sounds

Fistula formation:
● Colovaginal:purulent vaginal discharge
● Colovesicular: UTI symptoms, fecaluria
Pathophysiology
● Unclear
● Fecal matter or undigested food particles
may collect causing obstruction
● Obstruction may result in distention
secondary to mucous secretion &
overgrowth of normal colonic bacteria
● Vascular compromise may follow
● Alternatively, increased intraluminal pressure
cause erosion of the wall resulting in
inflammation, focal necrosis and possible
perforation
Anatomic Location
● 95% in sigmoid colon (small diameter,
highest pressure zone)
● 35% in proximal colon
● 4% right sided colon

Helps differentiate from appendicitis.

Also appendicitis typically manifests & climaxes
within 48 hours. Diverticulitis has slower
progression and achieves maximum expression
over a number of days.
Epidemiology
● Asymptomatic diverticulosis is common
● Incidence increases with age
○ <5% before 40 years
○ >65% by age 85 years

● 15-20% of patients with diverticulosis

develop diverticulitis
○ disease of elderly population (80%). Mean age at
presentation is 60 years
○ 20% of patients are <50 years
○ F>M in patients >50 years
Diagnosis
● Usually clinical based on H & P
● Other investigations help when the Dx is
unclear
Laboratory Tests
1. WBC count
a. leukocytosis & left shift
b. may be normal in elderly, immunocompromised or
less severely ill patients
2. Electrolytes
a. useful in patients with vomiting & diarrhea
3. RFTs
a. assess prior to use of IV contrast
4. LFTs & lipase
a. to exclude other causes of abdominal pain
5. UA & culture
6. Blood culture
Imaging
CT is considered the best imaging method for
confirmation of diagnosis. Sensitivity &
specificity with helical CT and colonic contrast
approach 97%.
Findings:
● Pericolic fat stranding due to inflammation
● Colonic diverticula
● Bowel wall thickening
● Phlegmon
● Abscesses
Other tests
1. Contrast enema
a. with water soluble solution, barium enema is
contraindicated because leakage into the
peritoneum would be catastrophic
b. useful when CT does not absolutely differentiate
between diverticulitis and carcinoma
2. Plain abdominal radiograph
a. not helpful in diagnosis but demonstrate bowel
obstruction and presence of free air
3. Endoscopy
a. not recommended in the acute setting (not
diagnostic & increase risk of perforation)
b. useful later to evaluate extent & r/o malignancy
Hinchey's Classification
Used to determine appropriate surgical
intervention in complicated diverticulitis
1. Stage l: Small or confined pericolic or
mesenteric abscess
2. Stage ll: Large abscess, often confined to
pelvis
3. Stage lll: Perforated diverticulitis causing
generalized purulent peritonitis
4. Stage lV: Rupture of diverticula into the
peritoneal cavity with fecal contamination
causing generalized fecal peritonitis
Management
● Mild (Hinchey's Stage l) usually treated as
outpatient
○ clear liquid diet
○ 7-10 days of oral broad spectrum antimicrobial
therapy
■ ciprofloxacin + metronidazole
■ TMP-SMZ + metronidazole
■ amoxicillin/clavulanic acid
○ Advance diet slowly as tolerated within 48-72 hours
● If resolved with conservative measures no
further treatment is required.
● Advise patient to follow high fibre diet
Indications for hospitalisation
● Severe diverticulitis (signs of systemic
infection or peritonitis)
● inability to tolerate oral hydration
● No improvement with out patient treatment
after 2-3 days
● Significant comorbidity
● Severe pain requiring paraenteral analgesia
In Patient Management
● Initiate bowel rest & IV hydration
● Initiate broad spectrum IV antibiotics (before
culture results)
● Monotherapy with beta-lactamase inhibiting
antibiotics or carbapenems are appropriate
(piperacillin/tazobactam,
ampicillin/sulbactam, imipenem)
● Multi drug therapy in severe disease:
metronidazole + 3rd generation
cephalosporin or floroquinolone.
(Aminogylcosides replaced to avoid risk of
In-Patient Management
Pain Management
● Morphine
● Meperidine a/w adverse effects
● NSAIDs and corticosteroids a/w greater
risk of perforation and should be avoid
In-Patient Management
2-3 days:
● fever, pain & leukocytosis should begin to
resolve
● Start clear liquid diet and advance as
tolerated
● Discharge if tolerating oral intake and stable
● Continue PO antibiotics (7-10days)
● Encourage high fibre diet
In-Patient Management
If patient is not improving or worsening
● Repeat CT to r/o abscess or complications
● Peridiverticular abscess >4cm (Stage ll): CT
guided percutaneous drainage
● For abscess with gross fecal material or
perforation: surgical intervention
Surgical Care
● 15-25% of 1st episode patients have
complicated disease necessitating surgery
● 18% surgical mortality rate
● Typically stage lll or lV requier emergent
surgery:
○ free-air perforation with fecal peritonitis
○ suppurative peritonitis (ruptured abscess)
○ uncontrolled sepsis
○ fistula formation
○ intestinal obstruction
○ failed therapy
○ immunocompromised
Surgical Care
● Recurrent episodes?? Elective surgery was
previously recommended
● Preoperative antibiotics should be given to
all patients
● A 2-stage surgical approach is the most
common emergent procedure currently used
Hartmann Procedure
Preferred approach in fecal or purulent
peritonitis and involves:

● Resection of the diseased segment of bowel

● End-colostomy
● Closure of the rectal stump

Typically 3 months later colostomy takedown

and colorectal anastomosis but is not always
done
Alternative Surgery
● Resection of the diseased colon
● Primary anastomosis
● Proximal diverting stoma: either colostomy
or ileostomy
Second procedure would be to close stoma.
Used primarily if there are contraindications to
primary anastomosis and absence or
purulent/feculent peritonitis.
Advantage: avoids difficult 2nd stage of
Hartmann
Elective Surgery

● Recommended after a second bout that

results in hospitalisation or complications
● Single stage resection is ideal
● 6 weeks after episode of acute disease
Is it cancer?
● Presence of a palpable mass usually favors
diverticulitis over colon cancer

○ cancer in the sigmoid colon rarely associated with a

mass because they are usually very small

○ a large phlegmon usually develops in diverticulosis

producing the palpable mass
Diverticulosis
Uncomplicated: incidental finding on
colonoscopy
CT Images
Enema
Hartmann's Procedure