Case 17: Iliac fossa pain
Thursday, April 28th, 2011Author: Dr Roshini Kulanthaivelu
A 35 year old gentleman with a history of Ulcerative Colitis and a rectal pouch formation, presented to the ED with a one day history of sudden onset, sharp, left to right iliac fossa pain associated with reduced bowel movements.
Initial observations were BP 127/74, HR 106, RR 22, O2 97%, T 37.2oC.
On examination, abdomen was mildly distended with generalised tenderness, guarding and tinkling bowel sounds. Empty rectum was found on PR examination.
These are his Xrays.
1. What is the diagnosis?
Click to see the answerBowel Perforation.
This is a surgical emergency and affects 2-14% of all patients with Ulcerative Colitis.
Ulcerative Colitis refers to autoimmune inflammation of the bowel, which characteristically only affects the inner mucosal layers and initially involves the rectum with distal spread along the digestive tract. Prevalence is estimated at 50 – 100 per 100 000 in the UK and usually affects young adults. Treatment consists of management of acute flares and maintenance of remission through aminosalicylates, corticosteroids and thiopurines or immunosuppressants such as methotrexate, ciclosporin or infliximab, with surgical treatment if medical management is ineffective.
This patient had undergone a complete colectomy and subsequent ileoanal pouch formation, in which a reservoir is created using the ileum and joined to the anus to create an artificial ‘rectum’ by means of a 3 stage surgery. This forgoes the need for a stoma in those patients without any remaining large bowel.
As you can see from the xrays above, this patient demonstrates distended small bowel with free air under the diaphragm, indicating perforation.
2. How would you treat this patient?
Click to see the answerInitial treatment consists of early liason with the surgical team and resuscitation with IV fluids, urinary catheterisation, NG tube and monitoring until the patient can be taken to theatre for emergency laparotomy ± bowel resection.
3. Name another complication of UC that often requires urgent surgical intervention.
Click to see the answerToxic Megacolon (TMC).
This refers to rapid dilation of the large bowel (>6cm) within 24hours, associated with either infection or inflammation. It is a life threatening complication of inflammatory bowel disease but can also occur as a result of infections such as Clostridium Difficile, ischaemia and radiation. It affects 1.6 – 3% of patients with UC and carries a mortality of 30%, often preceeding perforation.
Initial treatment is supportive with IV fluids, analgesia, broad spectrum antibiotics, corticosteroids, NG tube insertion and keeping the patient NBM. Urgent surgical intervention is required if there is persistent dilation or no improvement within 24 hours, or if there are further complications such as perforation, haemorrhage, and increase in colonic dilation.
4. What other indications exist for surgical treatment among patients with UC?
Click to see the answer• Severe Ulcerative Colitis that does not respond to corticosteroids.
• Chronic persisting colitis with poor response to medical therapy and poor quality of life in the outpatient setting.
• High grade dysplasia or cancer.
If medical therapy is unsuccessful, bowel resection is the only other available course of treatment. It is reported that as many as one third of patients with UC undergo colectomy within the first year of diagnosis, with a colectomy rate of 1% thereafter. UC patients are also at a 5-10 times greater risk of colorectal cancer.