Pelvic and sigmoid edema - Forum

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Scalpel

Pelvic and sigmoid edema - Ärzteforum

Post#1 »

A couple of months ago a 33 yo obese (274 lbs) fisherman from an off shore island presented with 3 to 4 days of increasing LLQ abd pain, T of 38.3, P 126 WBC 15,000. PE tender LLQ with peritoneal signs locally. Begun on broad spectrum antibiotics and tentatively diagnosed as diverticulitis. CT showed edema in sigmoid colon mesentery going into inguinal regional on L. No abcess. He became afebrile and WBC returned to normal within 48 hrs. On the seventh day he had a spike to 39 with a WBC of 15,000 once again and increased LLQ pain with what I thought was a mass. A repeat CT showed no abcess and improvement in the edema, etc in his pelvis. The next day he developed paresthesias in his L inner thigh and on exam I noted a LIH that I hadn't felt on admission (He had been in a lot of pain at that time). He returned to the island but over time has had a normal Barium enema with no abnormality of any kind. He now has pain related to the hernia which I plan to repair. Does anyone have any thoughts on what was going on when he presented? Could all of the pelvic and sigmoid edema be related to the hernia? He is big, but I think I would have detected something when he presented if the hernia was incacerated at that time.


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Billroth

Re: Pelvic and sigmoid edema - Ärzteforum

Post#2 »

Saw a very similar case, turned out to be a perforated diverticulum in a left inguinal hernia which was causing recurring Left inguinal abcesses!

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Surgeon

Re: Pelvic and sigmoid edema - Ärzteforum

Post#3 »

He's probably strangled an appendix epiploica in the hernia which might, in effect, produce the same story to mimic diverticulitis. I think most of us have seen this, but probably not diagnosed it pre-op. A hypaque enema by itself, or even at the time of CT might have helped rule out diverticulitis. In any event, he needs his colonic mucosa inspected, preferably with a flex/sigmoid, and a hernia repair under local anaesthetic. BTW, what is the feeling of Net members regarding contrast studies for acute diverticulitis? Never? Hardly ever? OK after a few days if pt settling (therefore little help in making the dx)? Routinely in first 24 hrs?

forceps

Re: Pelvic and sigmoid edema - Ärzteforum

Post#4 »

I believe that the key is the paresthesia in the inner thigh. This could be a partially incarcerated obturator hernia that reduced spontaneously.

Because you plan to repair his hernia anyway, I would do a Stopa repair, or, if you wish, a TEPP (which is really the same thing, done laparoscopically). With the Stopa repair, you can explore the obturator canal very nicely, and repair both at the same time. Since he is so big, the laparoscopic approach may be better.

Poland

Re: Pelvic and sigmoid edema - Ärzteforum

Post#5 »

First a Question - when you say under local, do you mean a field block or regional. We would do most of these fellows under a spinal.

Second - answer to your question - I'd trust my clinical acumen in making an initial diagnosis of diverticulitis, and do a Ba enema when settling to confirm diagnosis and define extent before planning any definitive treatment. If he didn't settle after a few days I'd probably do a laparotomy rather than an enema.

Third, a question, in the large gentleman's case would not a diagnostic laparoscopy be more fruitful, as the barium - if done reasonably has already given you a fair bit of information about the mucosa.

Scalpel

Re: Pelvic and sigmoid edema - Ärzteforum

Post#6 »

I use about 60cc's of 0.5%Xylocaine with 1/200,000 Adrenalin and 1 ampule of hyaluronidase(Wydase). I infiltrate as I go, taking care to block the ilioinguinal, iliohypogastric, genitofemoral nerves witha couple of cc's each, as well as the pubic tubercle, and the rest around the peritoeum of the sac. Formal blocks are unnecessary, and with experience, infiltration as you go along seems to work in all but the largest incarcerated ones, in which case spinal or epidural is better. Secondly, even though the Barium enema shows an apparently normal mucosa, and it is unlikely to harbour a carcinoma, granulomatous colitis is another possibility. Every so often a diverticulitis resection turns out to have Crohn's of the sigmoid, especially in a 39 yr old.

Scalpel

Re: Pelvic and sigmoid edema - Ärzteforum

Post#7 »

I personally wouldn't submit this guy to a general anaesthetic for a laparoscopy,unless I was clinically pretty sure he was acute enough to need surgical intervention, in which case a laparotomy would be done. I'm not a fan of laparoscopic hernias. To date I haven't had any major complications in my hernias. I believe that laparoscopic hernia repair has a significantly higher rate of MAJOR complications compared to conventional.

Hans

Re: Pelvic and sigmoid edema - Ärzteforum

Post#8 »

You say formal blocks are unnecessary, but wouldn't a spinal be quicker - though obviously if you are planning on day case surgery this is problematic. Incidentally what kind of repair do you do?

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