c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

The Acute Abdomen: 19

A D V E R T I S E M E N T

   
 

Diverticular disease can cause abdominal emergencies in a few ways. The inflammatory phlegmon itself may not respond to antibiotic treatment and bowel rest and require urgent surgery. A single, thin-walled diverticulum may perforate leading to diffuse peritonitis (see perforated diverticulitis.) A walled-off diverticular abscess may secondarily perforate causing diffuse peritonitis (see Hartmann's closure after diverticular abscess.)     

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The Acute Abdomen: 20

A D V E R T I S E M E N T

   
 

Vascular accidents may lead to bowel ischemia and infarction. Visceral emboli, most commonly from left atrial mural thrombus that breaks free when a fibrillating atrium converts to sinus rhythm, may shower to any mesenteric vessel. The superior mesenteric artery (see SMA embolus), with its acute angled takeoff is particularly vulnerable and dangerous because of the large vascular territory it supplies. Mesenteric vascular thrombosis may result from hypercoagulable states. Venous thrombosis can also compromise bowel viability. Polycythemia, liver disease and birth control pills are some predisposing factors. Mesenteric ischemia results in hyperperistalsis and severe colicy pain out of proportion to the findings on palpating the abdomen. Because peritonitis is not an initial feature of the pathology, such patients are often writhing around with the pain. The most dramatic abdominal vascular emergency results from abdominal aortic aneurysm (see retroperitoneal approach to abdominal aortic aneurysm.) Frank rupture leads to rapid death and such patients never reach a hospital. Those patients who are potentially salvageable have dissecting or leaking aneurysms. Visceral aneurysms (see superior mesenteric artery aneurysm and renal artery aneurysm), particularly splenic artery, may rupture. 

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The Acute Abdomen: 21

A D V E R T I S E M E N T

   
 

Non-occlusive mesenteric ischemia (see non-occlusive mesenteric ischemia) is equally dangerous in its effect, but is due to low flow from a variety of causes: bypass pump runs, low cardiac output after MI, and arterial spasm may all be implicated.      

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This page was last modified on 4/28/2006.