diverticular disease of git
TRANSCRIPT
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Diverticular disease of GITBy Dr: Mohamed Ezzat
Demonstrator of surgical oncologyOncology Center Mansoura
University
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before we startDef: A blind pouch that is continuous with the lumen of a hollow viscus.SitesTrue Vs FalsePulsion Vs traction
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Diverticular disease of the colon
Incidence• Common in western
countries (50% above 65 years).• Urban areas > rural areas.• ln Egypt it is less common
and is seen more in younger age groups.
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Etiology & PathogenesisChronic constipation>> ↑ intraluminal colonic pressure >>muscle spasm and incoordination>> herniation of colonic mucosa through the circular muscle layer between the taenia coli at the points of entry of blood vessels (pulsion diverticula).
False pulsion diverticula
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SiteSigmoid colon in 90% of cases. Any area of the colon may be involved. Rectum is never affected (as taenia coli becomes a continuous layer).
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Clinical picture
Asymptomatic (non complicated 80%)
Recurrent attacks of lower abdominal painDistension and flatulence.Accidentally discovered during enema (most common).
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Symptomatic (Complicated 20 %)
1- Acute diverticulitis.As acute appendicitis but on the left sidePerforation.Fistula formation.
2- Chronic diverticulitis.colon stricture and adhesive intestinal obstruction.
3- Bleeding per rectum.
May be the first presentation
Massive bright red bleeding
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Remember• The most common causes of massive
bleeding per rectum in old age are diverticular disease of the colon & angiomatous malformations.
• Colonic cancer is a common cause of fresh bleeding per rectum but not massive bleedings.
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InvestigationsRadiologyBarium enema (Most important tool)Early >> Saw-tooth appearance.Late >> Well-developed diverticula can be visualized.
NB: Barium enema and colonoscopy are contraindicated in acute diverticulitis as they can cause perforation.
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CT scanBest investigation in acute diverticulitis.lt reveals thickening of colonic wall, pericolic masses and abscesses.
Anqioqraphyln case of bleeding per rectum to localize the site of bleeding.
SigmoidoscopyWill detect the mouths of diverticula.Lt’s main value is to exclude carcinoma.Can detect bleeding from diverticula
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TreatmentUncomplicated1. High-fiber diet.2. Anti-spasmodics for the abdominal colic.
ComplicatedAcute diverticulitisHospitilizationBed rest, bowel rest.Antibiotics.Regular monitoring.
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Acute perforation >> Acute peritonitisClinical picture: Investigation: TTT : Explore , deal , toilet & drainage
Subacute perforation >> Localized abscess
Chronic perforation >> Fistula formationColovesicalColovaginalcolocutaneous
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Intestinal obstructionConservativeSurgery
BleedingResuscitation followed by angiography to localize the site of bleeding.lf localized regional resection lf localization fails total colectomy + ileorectal anastomosis.
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Meckel’s diverticulum
EtiologyPersistent patency of the proximal part of the vitellointestinal (Omphalomesenteric) duct.
Other anomalies?!
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Incidence
• 2% of people are affected.• 2% of affected people may have
complications.• 2 times more common in males
than females.• 2 feet (60 cm) from ileocaecal
junction.• 2 inches long.
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Clinical picture
Asymptomatic.CIP of complications.The most frequent manifestation is bleeding.
(The commonest cause of lower GIT bleeding in children) MCQ
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Complications• Intestinal obstructionintussusception: the ectopic mucosa at the base of the diverticulum acts as FB and forms the apex of an ileoileal intussusception.Volvulus• Peptic Ulcer• Diverticulitis and perforation• Litter’s hernia
Q: Strangulated hernia without intestinal obstruction?
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Differential diagnosis
• Appendicitis.• Salpingitis.• Perforated peptic ulcer.
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TreatmentSymptomatic cases:Excise longitudinally and closed transversely
Asymptomatic cases (accidently discovered in laparotomy)
Young fit patient >> ExciseOld patient with comorbidity >> Leave it
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