Mock6 Diverticulitis

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59-year-old, LIF pain, perforated diverticulitis. Hartman's procedure was done. Low BP, tachycardia, pyrexia.

What is your diagnosis?

Septic shock

Define septic shock?

Sepsis along with refractory hypotension not responding to fluid resuscitation and needs vasopressors.

Define sepsis?

Systemic inflammatory response along with infection.

Definition of septic shock according to what protocol?

qSOFA

Definition of Quick SOFA score?

Identifies high-risk patients for in-hospital mortality with suspected infection outside the ICU.
It includes 1 point for each of 3 criteria
RR ≥ 22 breaths/min
Altered mental status
Systolic BP ≤ 100 mmHg

What's lining of the mucosa of the colon?

Simple columnar epithelium

What is the layer below mucosa?

Submucosa

What are the contents of submucosa?

Blood vessels
Arcade
Connective tissue
Nerves

What is an abscess?

It is a localised collection of pus.
Pus is an exudate consisting of neutrophils, the liquefied debris of necrotic cells, and oedema fluid.
It may be caused by:
Seeding of pyogenic organisms into a tissue
Secondary infections of necrotic foci

What are the contents inside an abscess?

Typically has a central, largely necrotic region.
Rimmed by a layer of preserved neutrophils
Surrounding zone of dilated vessels and fibroblast proliferation indicative of attempted repair.

Cause of abscess in this patient? (how does it occur)

The diverticula became obstructed → high pressure & perforation

Why in pelvis?

Most dependant area

Define diverticular disease, diverticulitis and endometriosis?

Diverticular disease
Diverticula associated with symptoms.
Diverticulitis
Evidence of diverticular inflammation (pain, nausea, +/- fever)
Endometriosis
The presence of ectopic endometrial tissue at a site outside of the uterus.

If pt deteriorate with hypotension, tachycardia & bleeding tendency, possible causes?

Sepsis
DIC
ARDS

How does endometriosis cause pain?

Intrapelvic bleeding
Peri-uterine adhesions
Release of substance B

How does endometriosis get into the colon?

Regurgitation theory
The benign metastases theory
The metaplastic theory
Progenitor cell theory

Tissue samples from the operation show neutrophils, what does this mean?

Acute inflammation (Infection)

What is the structure of neutrophils?

Neutrophils have a segmented nucleus with a cytoplasm enriched with granules & secretory vesicles.

Types of granules?

1ry granules
Toxic mediators & bactericidal agents (proteolytic enzymes, cathepsin G, myeloperoxidase, elastase)
2ry granules (specific granules)
Toxic oxygen compounds, lysozyme & lactoferrin

How long is the life span of neutrophils?

12-16 hours.
Circulating half-life of 6-8h.
What are the contents of the cytoplasm?
Lysosomal enzyme (leucocidin)
Inflammatory cells in abscess?
Neutrophils

How do neutrophils arrive here?

Margination and rolling along the vessel wall
Firm adhesion to the endothelium
Transmigration between endothelial cells
Migration in interstitial tissues toward a chemoattractant stimulus

How to manage intra-abdominal collection in diverticulitis?

According to Hinchey classification for diverticulitis
Hinchey I: conservative management with antibiotics and liquid diet
Hinchey II: consider IR to drain the abscess
Hinchey III: consider less invasive approaches such as laparoscopic lavage and drainage
Hinchey IV: open surgery

Source of neutrophils?

Neutrophils generated in bone marrow with increased production during infection (10-fold).
Initial neutrophil recruitment (release from bone marrow) due to inflammatory mediators (such as cytokines, leukotrienes, and histamine)

admin

New questions:
Ask about complications of diverticulitis:
infects
perforation
obstruction

isurg

Mock6 Diverticulitis