Tuesday, August 17, 2004

When your colon is not your friend...
Sorry about the lack of posting. Busy week last week, but more on that later. An interesting case is that of a 50-ish gentleman who aboout 2 years ago underwent a sigmoid colectomy for malignancy. He was found to have a T3N2, stage III cancer. He did not follow-up for chemotherapy. He showed up in the ED last week with abdominal pain, leukocytosis, and a CT that looks like this:

Line pointing to the hydroureter on the left. Working our way down:

Uh oh. Looks like air where there shouldn't be any. Continuing:

What we have here is a psoas abscess with colonic inflammitory change consistent with diverticulitis. This also seems to be going on at the site of his previous colectomy for cancer. He had no peritoneal signs and had not been on any antibiotics. What to do? Any operative intervention at his point would have committed him to a colostomy, perhaps forever. So I had my radiologist colleauges lend a hand an they placed a CT-guided drain into the abscess. He improved with that and antibiotics. He is afebrile with a normal WBC and tolerating a diet. Follow-up CT:

Diminished size of the abscess, and some po contrast within the contained perforation. His CEA has risen to 98. My plan is to continue to let him "cool off" on antibiotics for a week or so and attempt resection with primary anastamosis. I may still have to divert him with an ileostomy. He will also need a ureteral stent.
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