christopher gross gillian lieberman, md march...
TRANSCRIPT
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