Case 7: Complex diverticulitis in a morbidly obese patient General Surgery CASE SUMMARY A woman in her late-50s with morbid obesity (BMI 54) was admitted to hospital A displaying hypotension and low oxygen saturation. She had an Adult Deterioration Detection System (ADDS) score of 3, elevated CRP of 217mg/L and reduced albumin (22g/L). She was known to have a colovaginal fistula, revealed via CT scan one month previously. The patient was diagnosed with diverticulitis, which was initially managed conservatively with antibiotics. Two days after admission she was observed to be dry retching, although taking sips of clear fluid. She was prescribed lactulose and Movicol® during the afternoon ward round. The following day, the patient had deteriorated. A CT scan showed a large bowel obstruction with a competent ileocaecal valve and dilated caecum; albumin had dropped to 19g/L. On day 4 of admission she underwent a Hartmann’s procedure (surgeon 1), with the caecum observed to be grossly distended. The bowel was decompressed via colostomies of the caecum and transverse colon. Some spillage of bowel content that occurred during the procedure was washed out. Postoperatively the stoma was dusky but viable; however, the patient did not improve (heart rate 110 bpm, BP 99/60 mm Hg, respiratory rate 18 bpm, oxygen saturation 96%, ADDS 5). Review by the acute pain service the following day noted the patient’s lack of improvement, with the anaesthetic registrar referring her to the surgical intern for review. On day 6 of admission there was a MET call for hypotension (heart rate 112 bpm, BP 89/65 mm Hg, oxygen saturation 90%, respiratory rate 28 bpm). The patient was sweaty with a tender abdomen. Primary diagnosis by the MET team was dehydration. The surgical principal house officer requested a CT scan to look for collections, as indications suggested that the patient was entering septic shock, with BP unresponsive to intervention, raised lactate and decreasing albumin. The management plan remained conservative with a non-contrast CT scan requested. At ICU ward round the following afternoon it was noted that her sepsis was not improving, but no mention was made of a possible re-look laparotomy. Another CT scan was requested. By 20:00 she had begun to deteriorate further; by midnight she was intubated and on a ventilator. On day 8 of admission, the family was counselled that the patient may not survive. She was returned to theatre (surgeon 2) where pus in 4 quadrants was washed out and 4 drains were placed. Her condition improved following the operation, although pus continued to leak from the left lower quadrant drain. By day 10 of
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NATIONAL CASE NOTE REVIEW BOOKLET
