What is your diagnosis?

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Septic shock

Define septic shock?

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

Define sepsis?

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Systemic inflammatory response along with infection.

Definition of septic shock according to what protocol?

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qSOFA

Definition of Quick SOFA score?

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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?

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Simple columnar epithelium

What is the layer below mucosa?

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Submucosa

What are the contents of submucosa?

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Blood vessels
Arcade
Connective tissue
Nerves

What is an abscess?

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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?

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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)

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The diverticula became obstructed → high pressure & perforation

Why in pelvis?

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Most dependant area

Define diverticular disease, diverticulitis and endometriosis?

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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?

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Sepsis
DIC
ARDS

How does endometriosis cause pain?

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Intrapelvic bleeding
Peri-uterine adhesions
Release of substance B

How does endometriosis get into the colon?

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

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

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Acute inflammation (Infection)

What is the structure of neutrophils?

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

Types of granules?

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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?

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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?

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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?

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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?

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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)