LOWER GI HEMORRHAGEDIVERTICULAR DISEASE

Dr.B.SELVARAJ MS;Mch;FICS:PROFESSOR OF SURGERY

MELAKA MANIPAL MEDICAL COLLEGEMELAKA 75150 MALAYSIA

DIVERTICULAR DISEASECauses of Lower GI Hemorrhage Clinical TypesA Classical Clinical vignetteEtiopathogenesisClinical featuresInvestigationsComplicationsManagementMindmapAlgorithm

Causes for Lower GI Hemorrhage

Diverticular diseaseAngiodysplasia- AV MalformationColorectal carcinomaHemorrhoidsFissure-in-anoIschemic colitisInflammatory bowel diseaseMeckel’s diverticulumUpper GI hemorrhage

DIVERTICULAR DISEASETwo Clinical Types:Diverticulosis: -The initial primary stage of the disease, wherein there is hypertrophy, muscular incoordination leading to increased segmentation and increased intraluminal pressure- resulting false diverticulum -At this stage they are asymptomatic, but often get severe spasmodic pain due to colonic segmentation called as painful diverticular disease.Diverticulitis: -The second stage due to inflammation of one or more diverticula with pericolitis. It presents with persistent pain, tenderness or occasionally mass in LIF

CLASSICAL CLINICAL VIGNETTEA 72 year old man had three large painless bowel movements that he

describes as BRBPR. The last one was two hours ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood.

BP: 150/70 mms of Hg; HR- 108/min; NS infusing at 200ml/hrPT, PTT & INR- Normal; Platelet count- 224,000, INR- 1.1Colonoscopy- revealed bleeding from sigmoid diverticulumDiagnosis: Bleeding sigmoid diverticulumAltered scenario: If Colonoscopy is negative do RBC tagged Tch99 scan

which may reveal bleeding from Angiodysplasia as little as 0.1 ml/min, If this is positive do CT angiogram which can localize bleeding more than 0.5ml/min and can do therapeutic embolization also

CLASSICAL CLINICAL VIGNETTE

45 yrs old lady was admitted for her 3rd episode of LLQ pain and fever in 18 months. She was given oral Ciprofloxacin and Metronidazole during her first episode. Second time she was admitted and given IV Ampicillin/Sulbactam and this episode lasted 3 days.

Temp: 102.4*F O/E: LLQ tenderness++ Labs: Total WBC- 17,000; Pregnancy test- Negative Spiral CT abdomen: Thickened sigmoid colonic wallDiagnosis: Diverticulitis

ETIOPATHOGENESISl .Colonic diverticula are mucosal out pouchings through the

submucosa and the muscular layer of the colon.2 .They occur most commonly in the sigmoid colon, and in 10%

of patients, they involve the entire colon.3.A disorder of modern civilization and is associated with

consumption of refined food products. It is rare in rural African and Asian populations where dietary fiber is high.

4. Long standing constipation increases the stool transit time and intraluminal pressure and causes diverticulosis.

5. They arise between antimesenteric taenia and the mesenteric taenia at the site of entry of the blood vessels.

DIVERTICULAR DISEASE

RISK FACTORS

CLINICAL FEATURESl .In western countries, 50% risk to develop diverticular disease

for an individual at the age of 60 years. Only 15% of patients with diverticulosis develop diverticulitis.

2. 75% of patients with diverticulitis have uncomplicated course, 25% of patients with diverticulitis develop complications like abscess, perforation,bleeding, stenosis and fistula.

3. Features of diverticulosis: Fullness of abdomen, bloating, flatulence, vague discomfort.

4. Features of diverticulitis: Pain in left iliac fossa which is constant radiates to back and groin, tenderness, bloody stool, often massive haemorrhage, fever, and mass in left iliac fossa.

CLINICAL FEATURES5. Generalised peritonitis as a result of free perforation presents

with the generalised tenderness, rebound and rigidity.6. Haemorrhage from colonic diverticula is typically painless and

profuse. When from the sigmoid, it will be bright red with clots, whereas right-sided bleeding will be darker.

7. The presentation of a fistula resulting from diverticular disease depends on the site. The most common colovesical fistula results in recurrent urinary tract infections and pneumaturia. Colovaginal, Colocutaneous and Coloenteral fistulas are rare

INVESTIGATIONS

1. Double Contrast Barium enema (best method to diagnose) shows “sawteeth” appearance. Champagne glass sign: partial filling of diverticula by barium with fecolith inside—seen in sigmoid diverticula.

2. Sigmoidoscopy is useful but should not be done in acute stage. Once acute stage subsides, barium enema, sigmoidoscopy, Colonoscopy can be done (To rule out associated malignancy).

3. Spiral CT scan in acute phase to see thickened colon and pericolic abscess 4. RBC tagged Tch99 scan: Find out bleeding as low as 0.1ml/min5. Mesenteric Angiogram: Find out bleeding > 0.5ml/min & therapeutic

embolisation

INVESTIGATIONS

INVESTIGATIONS

COMPLICATIONS1. Acute diverticulitis : A diverticulum may become inflamed

when a fecalith obstructs its neck. Patients present with left lower quadrant abdominal pain, fever, and leukocytosis.

2. Hemorrhage: Erosion of a peridiverticular vessel can lead to significant bleeding.

3. Diverticular abscess: Acute diverticulitis may result in a peridiverticular abscess. Patients experience severe pain, high fever, and white blood cell (WBC) elevation . A CT scan can identify the collection and guide percutaneous drainage.

4. Diverticular phlegmon: The local response to the diverticular inflammation may lead to formation of an inflammatory mass or phlegmon. Such patients need bowel rest and IV antibiotics .

COMPLICATIONS5.Diverticular stricture: Recurrent episodes of inflammation

may lead to fibrosis ,resulting in luminal narrowing. Patients may present with acute large bowel obstruction.

6.Fecal Peritonitis: Perforation of diverticula may lead to fecal peritonitis ,which has a mortality rate of about 50% . Patients need emergency exploratory laparotomy

7. Fistula: Peridiverticular abscess may erode into adjacent viscera, forming a fistula

DIVERTICULITIS

Hinchey Classification of Complicated Diverticulitis

Hinchey 1-pericolic or mesenteric abscess Hinchey 2-contained pelvic abscess Hinchey 3-generalized purulent peritonitis Hinchey 4-generalized feculent peritonitis

MANAGEMENT1. It is basically a benign condition, therefore the

prognosis is good. High fibre diet is advised.2. In acute diverticulitis/phlegmon, intravenous (IV)

fluids, antibiotics, and bowel rest are necessary.3. Abscesses should be drained, usually

percutaneously under CT guidance.4. Faecal peritonitis needs exploratory laparotomy.

The most commonly performed operation is the Hartmann procedure, in which the sigmoid colon is resected, the proximal colon is exteriorized as a stoma, and the rectal stump is oversewn

MANAGEMENT

5. Patients who develop strictures may need an elective sigmoid colectomy and primary anastomosis .

6. Fistulae are a complex problem. The patient's nutrition should be optimized, and infection should be controlled before surgical repair or resection is attempted.

7. In certain cases of diverticulosis, a longitudinal incision through the taenia and muscular layer without opening the mucosa is suffi cient (like Heller’s/Ramstedt’s myotomy)—Reilly’s sigmoid myotomy.

Mindmap- Diverticular Disease

Algorithm- Diverticulitis

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