christopher gross gillian lieberman, md march...

Diverticular

Disease

Christopher GrossGillian Lieberman, MDMarch 2008

Goals

DefinitionsEpidemiologyAnatomy PathophysiologySymptomsMenu of Diagnostic Modalities

Definitions

Diverticulum– sac-like protrusion of the colonic wall that consists of mucosa, submucosa, serosaDiverticulosis– the presence of diverticula, often an incidental findingDiverticulitis– inflammation resulting from a perforation of a diverticulumDiverticular Hemorrhage– Diverticular bleeding usually not associated with diverticulitis

Epidemiology

Age:Affects <5% before 40yo 30% at 60yo 65% at 80yo20% of those present with sxs

Risk factors:“disease of Western Civilization”

low fiber constipation obesity, lack of physical activityNSAIDssmoking

Anatomy

Pseudodiverticula– Herniations of mucosa and submucosacovered by serosa where vasa rectae penetrate the circular muscle layer

Between each side of the mesenteric taenia, and on one side of antimesenteric taeniae

www.accesssurgery.com “Current Surgical Diagnosis and Treatment”

http://www.meddean.luc.edu/

Pathophysiology

95% of diverticuli occur in the sigmoidIn Asians, 70% present as R-sided pain

Laplace’s law: (P=T/r), sigmoid has the smallest diameter and largest pressuresSegmentation exaggerated increase in intralumenal P

www.webmd.com

Patient: KB

51 yo

M who presents to ED with left lower abdominal pain and anorexia.

History of Present Illness

LLQ pain x 3wks; +distension and pressurePCP Rx Levofloxacin + Ciprofloxacin 2 wks priorNo Nausea/Vomiting+Bowel Movements, no BRPRP, no diarrheaAfebrile, HR: 96, BP: 156/89

More information . . .

PMHHTNHyperlipidemia?Sleep apnea?GERDHiatal Hernia

MedicationsHCTZ 25mg QDAtenolol 25mg QD

Physical Exam

Significant findings: tender LLQ to palpationDistended, +rebound

LabsElectrolytes, LFTs nlCBC: 16.0\___/336

/44.3\

Differential DDx:

Differential Diagnosis

Appendicitis, cholecystitis Ischemic colitis

Colorectal CA Mesenteric infarction

Cystitis Ovarian torsion

IBD PID, endometriosis

IBS Renal disease

Incarcerated Hernia SBO, LBO

Colorectal CA can have microperforations and become 2o infectedFollow-up colonoscopy is recommended in 6-8wks in a suspicious CT.

Clinical Presentation

Clinical Presentation

Incidence

LLQ pain 93-100%

Fever, chills 57-100%

Leukocytosis 69-83%

Nausea /Vomiting

20%

Mass

Constipation

Diarrhea

Urinary Sxs

What should we order for our patient?

Menu of Imaging

Goals: establish Dx and demonstrate the extent and severity of diverticulitis; ?complicationsMenu:

Barium Enema–largely outdatedCT—test of choiceUS—in pregnancy

Can be used in initial eval of lower abd pain, esp w/ femalesWill see hyperechogenicity surrounding bowel wall

Companion Pt 1: Diverticulosis

on Barium Enema

Double contrast used to be gold standard

Sensitivity: 82%Specificity: 81%

Shows divertics, with sigmoid narrowing, extravasation(+) Provided info on presence and degree of diverticula( - ) Cannot discern clinical relevance, missed Dx in 33%

C/I in cases of suspected perforation and emergencies

Luminal narrowingwww.radiologychannel.net/diverticuliti

CT: Test of ChoiceTriple contrast (IV, PO, rectal) now standardSensitivity– 85-97% (+) Can quantify diverticulitis to direct management, see presence of complications

CT based scoring system for diverticulitis Management

Stage 0 Mural thickening and diverticulae Conservative

Stage 1 Abscess/phlegmon

<3cm in diam Conservative in low risk patients

Stage 2 Abscess 5-15cm in diam CT-guided percutaneous

drainage orSurgery

Stage 3 Abscess beyond the confines of pelvis Surgery

Stage 4 Fecal peritonitis Surgery

Companion Pt 2: CT Manifestations of Diverticulitis

Pericolic fat infiltration (98%)Thickened fascia, wall thickening >4mm (78.9%)Muscular Hypertrophy (26.3%)“Arrowhead” sign (23.7%)Other signs of complications

Abscess (35%)Intramural sinus tract (with air or contrast) with thickened wall

FistulasPerforationObstruction

Fat stranding

Wall thickening

http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow228arr.jp

Companion Pt 3 + 4: Percutaneous

Drainage of Diverticular

Abscess

• Percutaneous

Drainage: Seldenger

Technique with 12 French gauge locking pigtail catheter

5cm abscess, Stage 2 Pigtail catheter

Halligan, et al. “Imaging Diverticular

Disease”http://www.emedicine.com/radio/images/336139‐367320‐6366.jpg

Thickened walls, sigmoid abscess

What does our patient’s CT show?

Our Pt KB: Pelvic Fistula on Pelvic CT

small sinus tract in pelvis communicating w/ rectosigmoid

colon, dilated sigmoid

Small sinus tractEnteroenteric

fistula

Colocolonic

fistulaPACS

6cm

Companion Pt 5 + 6: Fistulas on CT and Abd

Plain Film

2-10% of cases: Colovesical > colovaginal > coloenteric > colouteral

Air, stool, oral contrast in bladder

Air in bladderhttp://myweb.lsbu.ac.uk/dirt/museum/margaret/838-2454a-1480410.jpghttp://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html

Companion Pt 7: Perforation on Abd

CT

• Mortality for Stage III is 13% and Stage IV is 43%

Extraluminal

air

Stollman, et al. “Diverticular Disease of the Colon”

Treatment Recommendations

Elective Surgery: 6-8wks laterOne episode of complicated2 confirmed episodes that require hospitalizationImmunocompromised

CT scoring Management

Stage 0 Conservative–

Flagyl

+/-

Cipro; hospitalize if severe

Stage 1 Conservative

Stage 2 Drainage or Surgery

Stage 3 Surgery (Sigmoid resection with 1o

anastamosis)

Stage 4 Surgery (Hartmann procedure)

Our Pt KB: Hospital Course

Hospital course of Amp, Levo, FlagylPt was scheduled for a hemicolectomyFound to have rectosigmoid stricture during ex-lap

Low anterior resection (L hemicolectomy) with 1o

anastamosis to the rectum

Conclusion

Diverticulosis vs. diverticulitisInitial Presentation of DiverticulitisDiagnostic Menu: know the CT manifestations and their associated treatments

Thanks to:

• Dr. Gillian Lieberman• Dr. Andrew Hines-Peralta• Dr. James Kang

Works CitedBoulos PB “Complicated Diverticulitis” Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):649-662. Review Buchanan GN, Kenefick NJ, Cohen CR. “Diverticulitis”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):635-47. ReviewFerzoco LB, Raptopofhdfulos V, Silen W. “Acute diverticulitis”. N Engl J Med. 1998 May 21;338(21):1521-6. Review. Halligan S, Saunders B. “Imaging Diverticular Disease”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):595-610. Review Johnson CD, Baker M, Rice R, Silverman P, Thompson W. “Diagnosis of Acute Colonic Diverticulitis: Comparison of Barium Enema and CT” AJR 1987 March; 148: 541-546Makela J, Vuolio S, Kiviniemi H, Laitinen S. “Natural history of diverticular disease: when to operate? “Dis Colon Rectum. 1998 Dec;41(12):1523-8. Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons. “Practice parameters for sigmoid diverticulitis”. Dis Colon Rectum 2006 Jul;49(7):939-44. Salzman H, Lillie D. “Diverticular Disease: Diagnosis and Treatment” American Family Physician. 2005 Oct 1; 72(7): 1229-1233Shen SH, Chen JD, Tiu CM, Chou YH, Chang CY, Yu C. “Colonic diverticulitis diagnosed by computed tomography in the ED”. Am J Emerg Med 2002;20:552.Stollman N, Raskin J. “Diverticular Disease of the Colon”. The Lancet. 2004 Feb 21; 363: 631-639