Diverticulitis

You are the general surgery CT1 asked to see a 58-year old, overweight, woman who complains of 24-hour history of left lower quadrant pain, altered bowel habit and anorexia. She is a mildly pyrexic. How would you proceed?

Example answer introduction

I suspect that this lady may have diverticulitis. I would take a focused history, perform a focused examination and request the relevant investigations depending on my clinical suspicions. I would then initiate treatment and escalate to my registrar for senior review. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – inflammatory bowel disease, history of ureteric stones, previous abdominal surgery, smoking, diet (fibre), alcohol

  • Last meal

  • Events leading up to this point – nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – distention, surgical/traumatic scars, discolouration, hernia

  • Auscultate – bowel sounds

  • Palpate – Localised tenderness, guarding, rebound tenderness, Rovsing’s sign, peritonism

  • Percussion – Resonant

  • Digital rectal examination – I would ask for a chaperone –melena/fresh blood, masses, external genitalia – colovesical/colovaginal fistulae.

Example questions to progress the station

Q1 You suspect a diagnosis, what further investigations might you order in this case? 

I would then request the following investigations: 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

  • Depending on my findings she may require a CT abdomen and pelvis but I would discuss this with the registrar first. 

 

Q2 She is exquisitely tender in the left lower quadrant, with rebound tenderness and peritonism. She has temperature of 38.5, WCC 14, CRP 50, urine dip negative. The concerned A&E consultant has already arranged a CT abdomen and pelvis which has shown perforated sigmoid diverticulum with local abscess, how would you proceed?

Initial management

  • IV antibiotics according to local protocol 

  • Analgesia according to the WHO pain ladder

  • IV crystalloids to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Prep for theatre – she will need a laparotomy and sigmoid colectomy (Hartmann procedure. Inform emergency theatre, anaesthetist on call. 

  • VTE Prophylaxis

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation
I would inform the Registrar to review the patient in a timely manner, to ensure my diagnosis and management plan were correct.
Patients diagnosed with diverticulitis can be quite unwell, driven by sepsis. Discussion with critical care team may be necessary. 
Useful Resources

Commissioning guide: Colonic diverticular disease

Position paper: management of perforated sigmoid diverticulitis

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
core surgical training interview

© 2017-2020 BJK LTD

 

 

.Referral scheme

In collaboration with:

WWW.ENT-GURU.COM