Plain X ray of abdomen

Plain X-rays of the abdomen (supine, upright, and

diaphragmatic views) are useful for detecting free intra-
abdominal air, bowel gas patterns suggestive of small or large
bowel obstruction, and volvulus

Contrast studies
Contrast studies are useful for evaluating obstructive
symptoms, delineating fistulous tracts, and diagnosing small
perforations or anastomotic leaks.
Detection of small lesions can be extremely difficult,
especially in a patient with extensive diverticulosis. For this
reason, a colonoscopy is preferred for evaluating
nonobstructing mass lesions in the colon. Double-contrast
barium enema has been used as a back-up examination if
colonoscopy is incomplete.

Flexible sigmoidoscopy and colonoscopy

Sigmoidoscopes measure 60 cm in length.
Colonoscopes measure 100 to 160 cm in length and are
Xavier, 58 year old male capable of examining the entire colon and terminal ileum. 
Both sigmoidoscopy and colonoscopy can be used
presents with Diagnostics diagnostically and therapeutically.

Additional info
skips the usual morning ritual of going to the toilet to move his
bowel 
abdominal PHYSICAL EXAM
known smoker for about 45 years consuming about 4-5 sticks a constipation blood in stool Management: 
bloatedness
day, 
drinks alcohol almost every week only during weekends often to adequate resuscitation The patient is alert, cooperative, oriented but obviously Interpretation
NGT aspiration
point of intoxication.  identify source of hemorrhage uncomfortable. Indeterminate abdomen with feces filled with colon
Indications
3-4 episodes of watery stools a day since 2 days ago, described Causes: Management:  Vital signs: BP 140/70 mmHg HR: 100/min RR: 18/min
as brownish to dark colored, with 1-2 occasions of mucoid Temp: 36.7oC Height: 167 cm Weight: 75 Kgs. Hemorrhoids
metabolic melena hemetochezia Prostatitis developed moderate fever and abdominal distention
stools.  pharmacologic
experienced severe left  Abdominal exam reveals a globular abdomen, Prostate CA
endocrine bloody or non-bile secretions, or BPH clinical manifestations: On physical examination: 
iliac and hypogastric pain. increase return of bile normoactive bowel sounds, hypertympanitic, Anal and rectal CA
psychological  suggestive of upper intestinal left-sided abdominal pain, with/ hypertensive, tachycardic, tachypneic, febrile
neurologic fiber intake hemetochezia source soft with tender left iliac with no muscle guarding, no Anal condylomas without fever and leukocytosis
stricture increase fluid palpable masses Constipation abdomen was slightly distended, direct tenderness at left lower quadrant
mass
Fecal incontinence and muscle guarding, hypoactive bowel sounds and tympanitic Differentials: 
intake Anal fissures Diverticulitis
slow-transit constipation DRE: tight sphincter tone, enlarged palpable fleshy non
laxatives LGIB IBD - UC and Crohn’s ds
Colonic malignancy
outlet obstruction
source of bleeding distal to the
tender mass at the left lateral and right
Esophagogastroduodenoscopy ligament of Treitz (LGIB) anterior anus, smooth mucosa, brownish feces slight Pelvic pain
blood tinged flecks on gloved examining Contraindications
Patient was started Ertapenem 1gm IV once daily Groin pain
finger. Severe neutropenia IV hydration Inguinal hernia
Anatomic Vascular Neoplasm Inflammatory Prostatic abscess
Anoscopy and/or proctoscopy
(e.g. Diverticulosis) (e.g. Younger children - more careful
angiodysplasia,
ERTAPENEM
ischemia, failure to identify source of
bleeding
radiation-
induced)
Infectious Non-infectious Colonoscopy indications:
(e.g. Salmonella, (e.g.Crohn's Disease) Colonoscopy 1. + fecal occult blood LABORATORIES MOA used for
2. unexplained IDA
Shigella infection) Ertapenem exhibits bactericidal activity due inhibition treatment of complicated community-acquired intraabdominal
of cell wall synthesis mediated via binding to penicillin infections with adequate source control, including infections due
Stool Exam: binding proteins (PBPs). to resistant gram-negative organisms
RBC- high
Color : brown Work up:
Wbc- high
Consistency: soft CT, MRI, UTZ
Presence of
Microscopic: RBC/hpf - 35-40 E.histolytica cyst Contrast enemas/or endoscopy
WBC/hpf – 8-10 relatively contraindicated because
Ova and Parasites: E. histolytica cyst of risk of perforation
Bacteria: abundant

Blood type: O Rh+

CBC:
WBC – 13.6 K/uL RBC – 3.9 M/uL
Neu – 89.0 % Hgb – 11.3 g/dl Leukocytosis
Lym- 5.29% Hct – 34.0 Neutrophilic predominance
Mono – 5.36% MCV- 87.1 fL Hgb decreased - mild anemia
Eos – 0.169% Platelet – 259 K/uL
Baso – 0.195% RBC Morphology – Normal

FLAT PLATE AND UPRIGHT FILM OF

ABDOMEN: Exhibit A

The patient was given Metronidazole and

Diosmin + Hesperidin and was sent home.
Metronidazole
Against anaerobes
Amoebicidal
Trichomonacidal
Disrupts DNA and causes
breakage
TOC for amoebiasis

Interpretation Interpretation
Diosmin + Hesperidin Pericolic fat stranding at the sigmoid area likely due to inflammation, presence of colonic diverticula, The liver is not enlarged with normal echogenic pattern. There is no
Derived from plants bowel wall thickening, soft tissue inflammatory masses raising possibility of phlegmon, and abscesses at thickening of the Gallbladder wall with bile sludge. The biliary tree is not
the area of the sigmoid colon. Consider diverticulitis or colonic malignancy with pericolic abscess dilated. Pancreas and spleen are normal, the right kidney is normal in
Vascular protective effect formation. echopattern, renal calyces not dilated. The left
Supplements kidney is mildly echogenic with no pelvocalyceal dilatation. There are dilated
bowel loops which obscure the examination of the rest of the abdomen.

Diverticular Disease

CT SCAN findings:
Diverticulosis Diverticulitis
presence of diverticula without
Uncomplicated pericolic soft tissue stranding bowel resection
refers to inflammation and infection
Diverticulitis colonic wall thickening
inflammation associated with diverticula indications:
phlegmon
after 1st episode in children
after first episode of complicated
diverticulitis
outpatient immunosuppresed patients
Management
broad spectrum antibiotics for 7-days symptoms 
sigmoid colon most common site
(LLQ) resolve
with more severe pain perform colonoscopy after 4-6
hospitalized weeks to r/o malignancy
Patient showed give parenteral antibiotics
Management suspect abscess formation NO improvement bowel rest
after 48 hours.

upon

Hinchey Stage I and 2

CT scan
drain abscess percutaneously
Small abscesses (<2cm) may be treated with
Physical Further Imaging parenteral antibiotics 
Examination Larger abscesses are best treated with CT-guided
percutaneous drainage and antibiotics
patient deteriorates and/or
peritonitis

Abdomen: Hinchey Stage 3 and 4

laparotomy globular, tense, with direct
tenderness on LLQ and RRQ
w/ rebound tenderness,
muscle guarding, absent
bowel sounds, tympanitic
Febrile
1. abscess is inaccessible to percutaneous drainage
2. patient deteriorates or fails to improve  and proximal diversion
3. patient presents with free intra-abdominal air 
4. peritonitis
Upright Film
Interpretation
Presence of gas distended large
bowel loops; pattern nonspecific
and non-obstructive
pneumoperitoneum
Patients with larger abscesses, peritoneal soiling,
or peritonitis, sigmoid colectomy with end
colostomy and Harmann's pouch (most common)
or
Left Lateral Decubitus Film
Interpretation
Sigmoid colectomy with end colostomy, primary
Presence of gas on the patient's R
anastomosis, with or without on-table lavage,
side. Diverticulitis on the sigmoid
colon might have perforated
causing pneumoperitoneum
Made up of cushions of submucosal tissue,
Hemorrhoids vessels + smooth muscle fiber 

Graded depending on extent

Complicated - Diverticulitis with abscess, obstruction, diffuse

Diverticulitis peritonitis (free perforation), or fistulas

recommends to start screening
for malignancy at 50 years old
Adenocarcinoma
most common cancer of GIT
dominant risk factor: age (>50 years old)
other factors include: hereditary risk factors,
environment and dietary factors

advice patient:
1. a diet high in vegetable fibers
2. decrease alcohol intake
3. quit smoking Management: 
4. Take supplements such as calcium, selenium, Vit. A,c, and E, carotenoids

Management: 

Hinchey staging system

may progress to

FINAL
DIAGNOSIS

Diverticulosis with diverticulitis,

ruptured, Hinchey type III
Internal Hemorrhoids, Grade II