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A complicated case of diarrhoea

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2172 (Published 20 March 2014) Cite this as: BMJ 2014;348:g2172
  1. S Vandermolen, foundation year 1 trainee1,
  2. K Ewins, specialist registrar in medicine for the elderly1,
  3. S Perera, consultant radiologist2,
  4. J Wright, consultant general surgeon3,
  5. F Huwez, consultant medicine for the elderly physician1
  1. 1Department of Medicine for Elderly, Southend University Hospital, Southend SS0 0RY, UK
  2. 2Department of Radiology, Southend University Hospital, Southend, UK
  3. 3Department of Surgery, Southend University Hospital, Southend, UK
  1. Correspondence to: S Vandermolen s.vandermolen{at}southend.nhs.uk

An 82 year old man presented with a six day history of watery diarrhoea, vomiting, abdominal cramps, and confusion. He had a history of hypertension, gout, and prostate cancer, which was well controlled on hormonal therapy. He was independent and lived alone. He had not travelled or used antibiotics within the past two months.

On examination he appeared dehydrated, but was haemodynamically stable and afebrile. His abdomen was soft and non-tender, with normal bowel sounds. He had some erythema around the anus. The rectum was empty on digital examination.

Initial investigations showed a raised C reactive protein (178 mg/L, reference range 0-8; 1 mg/dL=9.52 nmol/L) and acute kidney injury (creatinine 125 µmol/L, 60-130; 1 µmol/L=0.01 mg/dL; urea 16.6 mmol/L, 2.3-6.7; 1 mmol/L=2.8 mg/dL). He was also noted to be hypokalaemic (potassium 3.0 mmol/L, 3.5-5.3). A plain abdominal radiograph was normal. Stool was negative for Clostridium difficile toxin but stool culture grew Campylobacter jejuni.

He was managed supportively with fluid resuscitation and received oral erythromycin 250 mg four times daily for five days. Diarrhoea became less frequent, but he remained unwell with persistent abdominal pain, persistently raised inflammatory markers, and renal dysfunction. He developed a palpable mass in the left iliac fossa. Abdominal computed tomography (figure) showed numerous outpouchings of the colon (arrow 1), with fatty stranding (arrow 2), which suggested acute inflammation. An irregular fluid collection containing an air bubble was also seen along the sigmoid descending junction (arrow 3).

Figure1

Abdominal computed tomogram showing numerous outpouchings of the colon (arrow 1), with fatty stranding (arrow 2), and an irregular fluid collection containing an air bubble along the sigmoid descending junction (arrow 3)

Questions

  • 1. On the basis of the patient’s history and radiological findings, what is the likely underlying cause?

  • 2. What are the complications of this condition and how are they graded?

  • 3. How would you manage this condition acutely?

  • 4. How would you manage this condition in the long term?

Answers

1. On the basis of the patient’s history and radiological findings, what is the likely underlying cause?

Short answer

The irregular fluid collection containing an air bubble is a pericolic abscess, probably a complication of underlying diverticular disease (as seen by the outpouchings of colon).

Long answer

The irregular fluid collection containing an air bubble seen on the abdominal computed tomogram is indicative of a pericolic abscess. The numerous outpouchings of the colon point to a diagnosis of underlying diverticulosis. The fatty stranding is indicative of acute inflammation, suggesting an attack of diverticulitis. He probably had a flare-up of previously undiagnosed diverticular disease, which led to the formation of a pericolic abscess.

Although diverticular disease is the most common underlying disease, pericolic abscess can also arise as a complication of inflammatory bowel disease, cancer, or gastrointestinal infection.1 2 Because stool culture was positive for C jejuni, infection may have also contributed to the formation of the pericolic abscess.

2. What are the complications of this condition and how are they graded?

Short answer

Complications include mild clinical inflammation; confined pericolic abscess; distant intra-abdominal, retroperitoneal, or pelvic abscess; generalised purulent peritonitis; and faecal peritonitis. Disease is graded according to the Hinchey classification.

Long answer

Diverticulosis is one of the most common gastrointestinal conditions in the developed world. It is estimated that 50% of people in the United Kingdom will have diverticula by the age of 50 years, and 70% by age 80 years. One in four people with diverticulosis will develop symptomatic diverticular disease, and 75% of these will experience at least one episode of acute diverticulitis.3

The clinical spectrum of diverticulitis ranges from mild clinical inflammation to life threatening feculent peritonitis, and it is graded according to the Hinchey classification (box). Our patient has stage 1 diverticulitis according to this classification.

Hinchey classification of acute diverticulitis45

  • Stage 1: Small or confined pericolic or mesenteric abscess

  • Stage 2: Pelvic, intra-abdominal, or retroperitoneal abscess

  • Stage 3: Perforated diverticulitis causing generalised purulent peritonitis

  • Stage 4: Rupture of diverticula into the peritoneal cavity with faecal contamination causing generalised faecal peritonitis

Non-inflammatory complications of chronic diverticular inflammation include stricture formation and the development of fistulas, most of which are colovesical or colovaginal.6

3. How would you manage this condition acutely?

Short answer

Acute management involves bowel rest, analgesia, and the use of oral or intravenous antibiotics. Percutaneous drainage is used for larger collections and those that do not respond to conservative management. In the acute phase, surgical resection is reserved for life threatening cases.

Long answer

Traditionally, oral or intravenous antibiotics, a clear liquid diet, ensuring that hydration is maintained, and paracetamol for pain are the mainstay of treatment for acute diverticulitis. Patients with mild uncomplicated diverticulitis can often be managed at home with this strategy.7 More recent studies suggest a lesser role for antibiotics in simple diverticulitis, showing no significant increase in complication or recurrence rates when antibiotics are not used.8 Admission is needed if pain cannot be managed with paracetamol alone, hydration cannot be maintained orally, oral antibiotics cannot be tolerated, or the patient is frail or immunocompromised.7 Admission is also needed when complications are suspected.

About 90% of small (under 2 cm) pericolic abscesses respond to conservative management with bowel rest, analgesia, and intravenous antibiotics alone.9 Most collections are caused by multiple organisms found within the colonic flora, so broad spectrum antibiotics, which cover anaerobic and Gram negative organisms, should be used.10 Common regimens include oral metronidazole to cover anaerobes, along with ciprofloxacin to cover aerobic organisms. Co-amoxiclav has some activity against both and is a good alternative.11 Antibiotics are typically given for 10-14 days depending on resolution of symptoms, although evidence for duration of treatment is lacking.8

A colonoscopy should be performed six weeks after resolution of symptoms and will confirm the diagnosis of diverticular disease in about 90% of cases. The risk of colonic cancer is high in this patient group, being found in 2-3%.12 Between 22% and 30% of patients admitted with an initial episode of complicated diverticulitis will go on to have a second episode.9

Larger abscesses or those that do not improve symptomatically with conservative treatment should be managed with percutaneous drainage. This may enable elective, rather than emergency, surgery to be performed and increase the likelihood of a successful one stage procedure.5

Despite treatment, 15-30% of patients admitted with acute diverticulitis will require surgery during the admission.9 Indications for emergency surgery are uncontrolled sepsis, fistula formation, bowel obstruction, purulent or faecal peritonitis, or failure of medical management.3 A Hartmann’s procedure reduces the failure rate of anastomosis when peritoneal contamination or severe bowel oedema are present and is the preferred approach in this scenario. If peritoneal contamination is not present, a primary anastomosis may be used. This approach has similar perioperative mortality and morbidity to those of a two stage procedure, but it removes the risks associated with stoma reversal.13 Emergency surgery carries a mortality rate of 18%.3

4. How would you manage this condition in the longer term?

Short answer

Patients with diverticulosis are advised to consume a high fibre diet and maintain an adequate fluid intake. In addition, bulk forming laxatives and paracetamol may be prescribed. Elective surgery is reserved for patients with recurrent acute diverticulitis and those with fistulas or strictures.

Long answer

The symptoms of diverticular disease vary in severity between cases, but typically include intermittent left sided abdominal pain, which may be exacerbated by food and relieved by the passage of stool or flatus. In addition, the patient may experience a change in bowel habit, or occasional large rectal bleeds.7 The goal of long term management of diverticular disease is to control symptoms and to prevent the development of serious complications.

Patients are advised to follow a high fibre diet plan, aiming to consume 18-30 g of fibre a day. Fibre from fruit and vegetable sources is thought to be preferable to cereal fibre. Patients should be advised of the importance of maintaining adequate oral fluid intake. Although some people immediately benefit from these changes, it may take as long as four weeks before symptoms improve.7

If diarrhoea or constipation predominate, supplementation with a bulk forming laxative may be of benefit.7 Pain should be managed by paracetamol alone. Opioids are not recommended owing to an associated increase in intra-abdominal pressure and resultant risk of perforation. Non-steroidal anti-inflammatory drugs also increase the risk of perforation and should be avoided.10

Patients should be educated to seek medical advice if they develop fever, uncontrolled pain, uncontrolled bleeding, or symptoms suggestive of serious anaemia.

Elective surgery for diverticular disease is considered on a case by case basis, but common indications are episodes associated with obstructive symptoms or contrast leakage, or the inability to exclude colonic cancer.9 The formation of a stricture or fistula is also an indication for surgical intervention.6 The previous standard approach of carrying out elective surgery after two episodes of acute diverticulitis is no longer accepted.14

Patient outcome

Our patient was treated conservatively with a seven day course of metronidazole and a five day course of co-amoxiclav. The initial outcome was excellent—his abdominal pain resolved, his stool consistency normalised, and his inflammatory markers returned to normal. He was discharged home 25 days after admission. The collection was not visible on an ultrasound scan at six weeks’ follow-up. Unfortunately, he presented four months later with large bowel obstruction. Computed tomography at this time showed marked diverticulosis and recurrence of the abscess. He underwent percutaneous drainage, which removed faeculent pus. He then underwent a laparotomy for incision and drainage of the collection, during which he had a Hartmann’s procedure. He recovered well from this procedure.

Notes

Cite this as: BMJ 2014;348:g2172

Footnotes

  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare following interests: None.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

References

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