Diverticular Disease

Introduction

. Colonic diverticula are aquired false diverticula in which mucosa and

submucosa protrude through the muscularis propria. Outpouchings occur

along the mesenteric aspect of the antimesenteric taenia where arterioles

penetrate the muscularis...

• Most common structural abnormality of the bowel.

In developed countries the prevalence has increased during the last

century:

- detection

- diet

- aging

Incidence Diverticula are rare before age 30 years ( < 2%), but the incidence

increases with age to a 75% prevalence after the age of 80 years

Sigmoid colon –m.c affected -is involved in over 95% of patients affected

with diverticulosis, perhaps owing to decreased luminal diameter and

increased luminal pressure,

In western countries left-sided diverticulitis predominates with right-sided

diverticulitis occuring in only 1.5%

10-25% of pts will develop diverticulitis

Etiology

low fiber diet ( high fiber diet protect against diverticulitis not

diverticulosis)

structural changes due to aging

decreased physical activity, obesity.

smoking.

constipation from any cause

Morphologic features

Macroscopic appearance of chroinc course of diverticular disease:

thickening and shortening of the bowel

decrease in caliber and increase in intra luminal pressure

mesocolon is also foreshortened, possibly as a result of chronic inflammation.

Presentation

Most patients are asymptomatic( 80%)

Occasionally, diverticulosis is associated with lower

(mostly left ) abdominal colicky or constant pain.

Diverticular bleeding: Most only have symptoms of

bloating and diarrhea but no significant abdominal

pain

Painless hematochezia , Start – stop pattern; “water

faucet” , Bright red blood no previous melena

complication Diverticulitis

Bowel obstruction

Fistula

Heamorrhage

Perforation

abcess

diverticulitis

uncompicated diverticulitis:

- local inflammation = Microperforations can develop in longstanding diverticula, leading to fecal extravasation and subsequent peridiverticulitis

- accounts for 75% of cases

- classical triad ( localized tenderness, fever and leukocytosis

complicated diverticulitis:

- obstruction.

- abscess or fistula formation.

- free perforation.

Diverticulitis Diverticulitis develops in 10% to 25% of patients with diverticula (90% left-sided, 10% right-sided).

Presentation: left-lower-quadrant pain (which may radiate to the suprapubic area, left groin, or back),

- fever,

- altered bowel habit

- urinary urgency.

Physical examination : the most common finding is localized left-lower-quadrant tenderness. The finding of a mass suggests an abscess or phlegmon

Diverticulitis Evaluation by CT scan and complete blood count (CBC) is the standard of care. CT fi ndings may include segmental colonic thickening, focal extraluminal gas, and abscess formation.

Neither sigmoidoscopy nor contrast enema is recommended in the initial workup of diverticulitis because of the risk of perforation or barium or fecal peritonitis, respectively

Diverticulitis Treatment is tailored to symptom severity. (a) Mild diverticulitis can be treated on an outpatient basis with a clear liquid diet and broad-spectrum oral antibiotics for 10 days

Severe diverticulitis is treated with NPO ,-but the patient could take clear fluid- , intravenous fluids, narcotic analgesics, and broadspectrum parenteral antibiotics (e.g., ciprofloxacin and metronidazole).

-----A low fiber diet diet is resumed after 1 week of pain-free tolerance of a liquid diet.

------A high fiber diet is resumed after 4-6 week .

Diverticulitis . Fiber supplements and stool softeners should be given to prevent constipation.

A colonoscopy or water-soluble contrast study must be performed after 4 to 6 weeks to rule out colon cancer, infl ammatory bowel disease (IBD), or ischemia as a cause of the segmental infl ammatory mass

Elective resection for diverticulitis usually consists of a sigmoid colectomy.

Recurrence rate ??1st ,2nd episode .

Abcess most common complication of acute diverticulitis

Diverticular abscess is usually identifi ed on CT scan.

A percutaneous drain should be placed under radiologic guidance.

This avoids immediate operative drainage, allows time for the infl ammatory phlegmon to be treated with intravenous antibiotics.

Generalized peritonitis

-----Surgery is principally directed to control sepsis in the peritoneum and circulation

Vigorous resuscitation and antibiotic therapy is still warranted , Opoid analgesia , Oxygen therapy , Urinary catheter to assess hourly urine out put

Primary resection and anastomosis after on table lavage in selected case

Hartman‟s procedure : Resection of sigmoid colon with formation of end colostomy , rectal stump (two stage ..3 month later colostomy takedown and colorectal anastomosis ) We do it when condition do not favour primary anastomosis

Fistula

Fistula ( secondary to diverticulitis ,5% of complicated diverticulitis)

Spontaneous

iatrogenic

Types:

colocutaneous:

- spontaneous.

- post abscess drainage.

- postoperative

Fistula

colovesical:

- most common.

- more in males.

- recurrent urinary sepsis, urgency, pneumaturia.,reccurent uti

- CT fi ndings of air and solid material in a bladder confirm the diagnosis. Lower endoscopy, barium enema, intravenous pyelography, and cystoscopy often fail to demonstrate the fi stula

coloenteric:

- abscess discharge through the small bowel.

- diarrhea.

- may be asymptomatic – uncommon- and may be entirely asymptomatic

or result in corrosive diarrhea

.

colovaginal:

- passage of flatus and feces through the vagina.

- recurrent vaginal infection.

- more common after hysterectomy.

.

colovaginal:

- passage of flatus and feces through the vagina.

- recurrent vaginal infection.

- more common after hysterectomy.

--The fistula may be difficult to identify on physical examination or the

previously mentioned tests.

-The presence of methylene blue staining on a tampon inserted in the

vagina following dye instillation in the rectum is diagnostic.

Bleeding

usually associated with diverticulosis rather than diverticulitis.

colonoscopy is mandatory to exclude malignany.

rebleeding rate is high

Right colon is the source of diverticular,bleeding in 50-90% of patients

Why there is risk for bleeding ???

In 60% of cases

The media of the perforating artery adjacent to the colonic diverticulum

may become attenuated and eventually erode. This arterial bleeding

usually is bright red and is not associated with previous melena or

chronic blood loss.

Possible reasons

Right colon diverticuli have wider necks and domes

exposing vasa recta over a great length of injury

Thinner wall of the right colon

How to manage bleeding ???

stops spontaneously in most cases 80%

treatment: colectomy, embolization,cautery, clip,

Urgent resection of the affected colonic segment should be considered in

patients with active ongoing bleeding ( > 6 units packed red blood cells

(RBCs)/ 24 hours).

Elective resection of the affected colonic segment should be performed in

patients with recurrent bleeding or need for longterm anticoagulation or in

those in whom excessive blood loss may be poorly tolerated

Cont.

Obstruction:

luminal stenosis or extrensic compression from an abscess.

small bowel obstrucion or colonic obstruction

treatment: Hartman„s, tubular resection, stent.

DD with malignancy!!!!

Giant colonic Diverticulum

Extremly rare

Most occur on the antimesenteric side of the

sigmoid colon

Pts may be asymptomatic or may present with,vague abdominal

complaints such as pain,nausea, or constipation.

Barium enema is usually diagnostic.

Complications of a giant diverticulum include ,stasis ,perforation,

obstruction, and volvulus.

Resection of the involved colon and diverticulum is,recommended

Classification of diverticulitis

Hinchey classification:

Stage I: diverticulitis with associated pericolic abscess.

Stage II: diverticulitis associated with distant abscess (pelvic)

Stage III: diverticulitis associated with purulent peritonitis.

Stage IV: diverticulitis associated with fecal peritonitis.

Stages I and II: antibiotics and drainage especially for large abcess .

Stages III and IV:

occurs in 1-2% of cases

Mortality 20-30%

treatment: surgery

Investigations for diverticular disease

Single /double contrast study =Barum enema , show saw tooth

CT scan

-IV / orall enhanced CT scan

-if the Iv or oral enhancement is contraindicated ,so go for nonenhanced

CT scan

Colonoscoy (after resolution of acute attack) ,it is delayed until 6 weeks

after acute attack of diverticculitis , biopsy is taken if possiple

Management

The majority can be managed conservatively(high fiber diet , bulk forming laxative , antispasmodic if reccurent pain, antibiotic for diverticulitis –gram negaative +anaerobe )

IV antibiotics that cover G-/anaerobe for 3-5 days

then switch to oral to complete 10-14days

Ex : ceftriaxone + metronidazole

Or – Ampicillin-sulfabactam

_ Ticarcillin-Clauvalanate

Cont.

15-25% will require surgery during the initial complicated attack.

For those who experienced 2nd attack, 60% of them will have complications.

After recovery from the 3nd attack, only 10% remain asymptomatic

Recovery after the first attack can be expected in over 70% of patients versus 6% after the third episode.

Indications for surgery:

* colonic obstruction

* fistula

* in some cases of bleeding

* recurrent diverticulitis.

Cont.

-The American Society of Colon and Rectal Surgeons has appropriately

recommended consideration of elective sigmoid colectomy after recovery

from acute diverticulitis on a case-by-case basis, with the decision based

on the:

- Age

- comorbid disease

- the frequency and severity of the attacks

- whether symptoms persist after the acute episode

Figure Colonic

diverticula in the left

colon on

radiography with

barium enema.

Single contrast –barium enema study, high-resolution

CT scan enhanced and IV contrast

high-resolution CT scan

Radiograph film with barium enema

Saw tooth appearance

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