colonic diverticulosis: a review dr. matt w. johnson bsc mbbs mrcp md consultant gastroenterologist

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  • Slide 1
  • Colonic Diverticulosis: A review Dr. Matt W. Johnson BSc MBBS MRCP MD Consultant Gastroenterologist
  • Slide 2
  • Diverticulosis
  • Slide 3
  • Operative Picture
  • Slide 4
  • Introduction Diverticular ? disease (or Variant of normal ?) Diverticular ? disease (or Variant of normal ?) Prevalence = 40% in those >50y Prevalence = 40% in those >50y 70% of those >80y 70% of those >80y 68,000 Hospital admissions / year in UK 68,000 Hospital admissions / year in UK 2,000 deaths / year in UK 2,000 deaths / year in UK Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial number NCT00663247. 2010 Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial number NCT00663247. 2010 Diverticular disease and diverticulitis, Clinical Knowledge Summaries (March 2008) Diverticular disease and diverticulitis, Clinical Knowledge Summaries (March 2008) Diverticular disease and diverticulitis, Diverticular disease and diverticulitis,
  • Slide 5
  • Diverticulosis Demand on L&D Services 70-80% of new patient clinic appointments are for ABHs 70-80% of new patient clinic appointments are for ABHs Over the last 7y = 12,000 FSs Over the last 7y = 12,000 FSs Of these;- Of these;- 5,500 = Normal 47% 500 = Haemorrhoids East (soluble fibre) rare in Africa Insoluble stool fibre = increases stool bulk = larger colon diameter = impaired segmental contractions = higher intra-luminal pressures Insoluble stool fibre = increases stool bulk = larger colon diameter = impaired segmental contractions = higher intra-luminal pressures 1 Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005
  • Slide 13
  • Idiopathic Slow Transit Constipation Day 5 after taking markers
  • Slide 14
  • Diverticulosis 75% = most found incidentally 75% = most found incidentally When questioned most will have symptoms ie = Diverticular disease When questioned most will have symptoms ie = Diverticular disease No proven evidence that Mx helps prevent enlargement or further development of diverticulae No proven evidence that Mx helps prevent enlargement or further development of diverticulae
  • Slide 15
  • Epidemiology - Location Classically Sigmoid Classically Sigmoid In Orient often right-sided In Orient often right-sided Rectal Sparing Rectal Sparing Can occur anywhere e.g. Small bowel Can occur anywhere e.g. Small bowel
  • Slide 16
  • Diverticulosis Right SidedLeft Sided
  • Slide 17
  • Diverticular Disease Altered bowel habits (pellets / loose) Altered bowel habits (pellets / loose) Bloating / Flatulence / Borborygmi Bloating / Flatulence / Borborygmi Incomplete evacuation Incomplete evacuation LIF discomfort relieved by defaecation LIF discomfort relieved by defaecation Mx = Soften and shift stool Mx = Soften and shift stool High fluid >2L/d Low residue (high soluble fibre) diet +/- Movicol 1 sachet bd +/- Mesalazines +/- Buscopan / Spasmolol / Colperamin / Mebeverine Avoid opioids + Loperamide
  • Slide 18
  • Slide 19
  • Diverticulitis Cause Cause Inspissation of faecal content stuck in diverticlum Obstruction of the diverticulum Increased pressure = local ischaemia + breakdown of mucosal barrier Localise bacterial overgrowth + translocation across membrane = micro-abscesses
  • Slide 20
  • S+Ss of Diverticulitis Symptoms LIF pain (can be right sided) LIF pain (can be right sided) ABH / Diarrhoea ABH / Diarrhoea N+V N+VSigns Pyrexia (Temp > 38C) Pyrexia (Temp > 38C) Wbc(>12) Wbc(>12) ESR or CRP ESR or CRP CXR + AXR CXR + AXR US < CT scan(exclude complications eg. abscess) US < CT scan(exclude complications eg. abscess)
  • Slide 21
  • Management Ix Bloods Bloods Rectal examination (avoid sigmoidoscopy for 2 weeks) Rectal examination (avoid sigmoidoscopy for 2 weeks) CXR CXR AXR AXR USS or CT Scan USS or CT ScanMx Resuscitation IV fluids Resuscitation IV fluids Antibiotics Antibiotics Analgesia Analgesia Operative intervention Operative intervention
  • Slide 22
  • Hinchney Classification of Diverticulitis GradeExtentMortalityPrognosis 1 Localised abscess