COLONIC DIVERTICULAR DISEASE

* US Census Bureau, International Data Base, 2004 ( the extrapolations for Diverticular Disease are only estimates and may have limited relevance to the actual incidence of Diverticular Disease in any region)

TYPES

FALSE DIVERTICULA- involves only protrusion of the mucosa through the muscularis propria of the colon- most common

TRUE DIVERTICULA- a saclike herniation of the entire bowel wall

Protrusion occurs at the point where the NUTRIENT ARTERY or VASA RECTI penetrates

through the muscularis propria

Break in the integrity of the colonic wall

Compression or erosion

PERFORATION BLEEDING

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

commonly affect the SIGMOID COLON due to:

Relative high pressure zone within the muscular sigmoid colin.

Higher amplitude contractions combined with constipated, high fat content stool within the sigmoid lumen results in the creation of these diverticula

Related to retention of particulate material within the diverticular sac and formation of fecalith

Presentation, Evaluation, and Management

Diverticular Bleeding• Hemorrhage from a colonic diverticulum is the most common

cause of hematochezia in patients >60 years.• Only 20% of patients with diverticulosis will have GI bleeding.• Most bleeds are self-limited and stop spontaneously with

bowel rest.• Lifetime risk of rebleeding: 25%

Diverticular Bleeding• Colonoscopy

To localize the bleeding May be both diagnostic and therapeutic in the management of mild to

moderate diverticular bleeding

• Angiography Management of massive bleeding in a stable patient Mesenteric angiography can localize the bleeding site and occlude the

bleeding vessel successfully with a coil in 80% of the cases Follow up: Repetitive colonoscopy to look for evidence of colonic

ischemia

• Segmental resection of the colon To eliminate risk of further bleeding In patients on chronic blood thinners

Diverticular Bleeding•Highly selective coil embolization

Rate of colonic ischemia: <10% Risk of acute rebleeding: <25%

•Selective infusion of vasopressin To stop hemorrhage Complications: MI, intestinal ischemia Recurrence of bleeding in 50% of patients once infusion is

stopped

Diverticular Bleeding•Surgery

Indications: if patient is unstable or has had a 6-unit bleed within 24 h

Total abdominal colectomy Patients with presumed bleeding from diverticular

disease requiring emergent surgery without localization Rationale: Colonic diverticulosis is more often seen from

the R colon Surgical resection with primary anastomosis

In patients without severe comorbidities

Presentation, Evaluation, and Management

DIVERTICULITISUncomplicated – 75%Abdominal PainFeverLeukocytosisAnorexia/obstipation

Complicated – 25%Abscess 16%Perforation 10%Stricture 5%Fistula 2%

Diverticulitis•Diverticular perforation

Generalized peritonitis in <25% of cases (+) Abdominal distention

•Giant diverticulum of the sigmoid (+) Air fluid level in the LLQ on plain abdominal film Mx: resection to avoid impending perforation

Diverticulitis•Diagnosis is best made on CT.

Diverticulitis•Suspected diverticulitis that does not meet CT

criteria or is not associated with a leukocytosis or fever is not diverticular disease

•Conditions that mimic diverticular disease: IBS Ovarian cyst Endometriosis Acute appendicitis PID

Diverticulitis•Barium enema or colonoscopy

Should be performed ~6 weeks after an attack of diverticular disease A sigmoid malignancy can masquerade as diverticular

disease. Should not be performed in the acute setting

Higher risk of colonic perforation associated with insufflation or insertion of barium-based contrast material under pressure.

Diverticulitis•Complicated diverticular disease

Diverticular disease associated with an abscess or perforation, and less commonly with a fistula.

With fistula formation Common locations include cutaneous, vaginal or vesicle

fistulae Present with either passage of stool through skin or

vagina, or pneumaturia Colovaginal fistulae: more common in women who have

undergone hysterectomy

Hinchey Classification of Perforated Diverticular Disease

Medical Management of Diverticular Disease•Asymptomatic

Diet alterations – fiber-enriched diet, including 30g of fiber/day

Supplementary fiber products: Metamucil, Fibercon, Citrucel

Avoid nuts and popcorn – may obstruct the lumen of the diverticulum

Medical Management of Diverticular Disease• Symptomatic

Radiographic and hematologic confirmation of inflammation and infection within the colon

Treated initially with antibiotics and bowel rest TMP-SMX or ciprofloxacin and metronidazole (+) Ampicillin – for nonresponders Alternative: IV piperacillin or oral penicillin/clavulinic acid Usual course: 7-10 days Rifixamin + fiber – less frequent recurrent symptoms from

uncomplicated diverticular disease

Limited diet until pain resolves Medical therapy can be continued beyond 2 attacks without an

increased risk of perforation requiring a colostomy, especially in those >50 years.

Surgical Management ofDiverticular Disease• In patients who are low risk (ASA I and II) who have

had at least 2 documented attacks requiring hospitalization or those who do not rapidly improve on medical therapy

•Younger patients – more aggressive form of disease▫Waiting beyond two attacks is not recommended.

• In all low surgical risk patients with complicated diverticular disease

Surgical Management ofDiverticular Disease•Goals of Surgical Management

Control sepsis Eliminate complications such as fistula or obstruction Remove diseased colonic segment Restore intestinal continuity

Surgical Management ofDiverticular Disease

Surgical Management ofDiverticular Disease

• Open or laparoscopic sigmoid resection – current option of uncomplicated diverticular disease

• Benefits of laparoscopic over open resection:▫Early discharge (by at least 1 day)▫ Less narcotic use▫Earlier return to work

• Benefits of open over laparoscopic resection:▫Shorter operative procedure▫ Less costly

• Complication rates are similar.

Surgical Management ofComplicated Diverticular Disease

Proximal diversion of the fecal stream with an ileostomy or colostomy and sutured omental patch with drainage

Resection with colostomy and mucus fistula or closure of distal bowel with formation of a Hartmann’s pouch

Resection with anastomosis (coloproctostomy)

Resection with anastomosis and diversion (coloproctostomy with loop ileostomy or colostomy)

Surgical Management ofDiverticular Diseases•Hinchey Stages I and II

▫Percutaneous drainage followed by resection with anastomosis about 6 weeks later

▫Percutaneous drainage For abscesses ≥ 5 cm with a well-defined wall that is

accessible If <5cm, may resolve with antibiotics alone Contraindications to percutaneous drainage:

No percutaneous access route Pneumoperitoneum Fecal peritonitis

Surgical Management ofDiverticular Diseases•Hinchey Stages I and II

▫If patients develop generalized peritonitis Hartmann’s procedure

▫Nonoperative therapy – 20% recurrence rate at 2 years in patients with Hinchey Stage I disease

▫80% of patients with Hinchey Stage II required surgical resection for recurrent symptoms.

Surgical Management ofDiverticular Diseases• Hinchey Stage III

▫Hartman’s procedure or with primary anastomosis and proximal diversion

▫ If patient has significant comorbidities: intraoperative peritoneal lavage (irrigation), omental patch to the oversewn perforation, and proximal diversion of the fecal stream with either an ileostomy or transverse colostomy can be performed

• Hinchey Stage IV▫No anastomosis of any type should be attempted.

Recurrent Symptoms inDiverticular Disease•Occurs in 10% of patients.•Recurrence develops in patients following

inadequate surgical resection.•A retained segment of diseased rectosigmoid colon is

associated with twice the incidence of recurrence.• IBS – may also cause recurrence of initial symptoms•Patients undergoing surgical resection for presumed

diverticulitis and symptoms consistent with IBS have functionally poorer outcomes.