Diverticular Disease

1
Diverticular Disease

• H.K. Oh M.D.
• Department of General Surgery

2
(No Transcript)
3
Overview

• A diverticulum is an abnormal sac or pouch
  protruding from the wall of a hollow organ.
• Diverticula pouches
• Diverticulosis condition of having diverticula
• Diverticulosis is a common condition of Western
  society and seems to be an unfortunate product of
  the Industrial Revolution.
• Decreased consumption of unprocessed cereals
  along with the increased consumption of sugar and
  meat
• The formation of diverticula is also related to
  aging
• Rare in individuals younger than the age of 30
  years, but at least two thirds of Americans will
  have developed colonic diverticula by the age of
  80.

4
Pathogenesis

• Diverticula are actually herniations of mucosa
  through the colon at sites of penetration of the
  muscular wall by arterioles
• On the mesenteric side of the antimesenteric
  teniae
• Sigmoid colon
• The most common site (50)
• The smallest luminal diameter.
• Low fiber diet -gt decreased colonic luminal
  content -gt high intraluminal pressures to propel
  the feces forward -gt herniations of
  mucosa through the anastomically weak points in
  the colonic wall

5
Diverticular bleeding

• The most common cause of hematochezia in patients
  over the age of 60
• 20 of patients with diverticulosis will have GI
  bleeding.
• Risk factor HT, Artherosclerosis, NSAID
• Usually self limited, but rebleeding risk (25)
• Localization Colonoscopy, Angiography
• Surgery
• Unstable hemodynamics, 6-unit bleed within 24 hr
• Without localization Total colectomy

6
Diverticulitis

• Definition
• Inflammation of a diverticulum, is related to the
  retention of particulate material within the
  diverticular sac and the formation of a fecalith
• Actually an extraluminal pericolic infection
  caused by the extravasation of feces through the
  perforated diverticulum
• Presentation
• LLQ pain may radiate to the suprapubic, groin,
  back
• Bowel habit change, Anorexia, Fever, Chill,
  Urinary urgency

7
Diverticulitis

• Physical Findings
• Dependent on the site of perforation, the amount
  of contamination, and the presence or absence of
  secondary infection of adjacent organs
• Tenderness, Muscle guarding
• Tender mass phlegmon or abscess
• Abdominal distension ileus or obstruction
• Tender fluctuant pelvic mass on rectal or vaginal
  exam

8
Diverticulitis

• Diagnostic Tests
• CT
• The preferred test to confirm the suspected
  diagnosis
• Location of infection, extent of inflammatory
  process, presence and location of an abscess,
  secondary complications
• sigmoid diverticula, thickened colonic wall gt4
  mm, inflammation within the pericolic fat the
  collection of contrast material or fluid
• MRI, US
• Water soluble contrast enema
• Distinguish acute diverticulitis from perforated
  cancer
• Risk of increasing the colonic pressure,
  extravasation of feces through the perforated
  diverticulitis

9
Uncomplicated Diverticulitis

• Disease not associated with free intraperitoneal
  perforation, fistula formation, or obstruction
• Nonoperative treatment
• Bowel rest Antibiotics 75 response
• Trimethoprim/sulfamethoxazole or ciprofloxacin
  and metronidazole aerobic gram-negative rods
  and anaerobic bacteria
• The addition of ampicillin to this regimen for
  nonresponders enterococci
• Single-agent therapy a third-generation
  penicillin such as piperacillin
• The usual course of antibiotics is 7 to 10 days

10
Uncomplicated Diverticulitis

• Investigative studies
• After the symptoms have subsided for at least 3
  weeks
• To establish the presence of diverticula and to
  exclude cancer, which can mimic diverticulitis
• Colonoscopy gt Barium enema
• Recurrent disease
• Second attack (lt25) -gt Third attack (gt50)
• Elective resection
• After infection control usually 4 to 6 weeks
  after the episode
• Laparoscopic resection growing trend
• Immunocompromised patient after single attack

11
Complicated Diverticulitis

• Hinchey classification
• Stage I Pericolic or mesenteric abscess
• Stage II Walled-off pelvic abscess
• Stage III Generalized purulent peritonitis
• Stage IV Generalized fecal peritonitis

12
Complicated Diverticulitis Abscess

• Usually confined to the pelvis
• Significant pain, fever, and leukocytosis
• More than 2cm should be drained
• Percutaneous or transanal gt laparotomy
• Elective surgery after 6weeks following
  drainage
• Complete removal of the entire abnormally
  thickened bowel

13
Complicated DiverticulitisFistula

• Skin, bladder, vagina, or small bowel
• Sigmoid-vesical fistula
• Pneumaturia, fecaluria, and recurrent UTI
  (Urosepsis)
• CT may demonstrate air in the bladder
• Barium enema, IVP, Cystoscopy
• Treatment
• Initial treatment infection control and reduce
  the associated inflammation
• Rarely a cause for emergency surgery
• Diagnostic steps such as coloscopy should be
  taken to confirm the cause of the fistula before
  a definitive operation is undertaken.

14
Generalized Peritonitis

• Mechanism
• Perforation without sealing by the bodys normal
  defenses -gt contaminated with feces
• Abscess burst into the unprotected peritoneal
  cavity -gt contaminated with enteric bacteria
• Immediate operative intervention
• Excise the segment of colon containing
  perforation and construct a colostomy using
  noninflammed colon
• Peritoneal cavity irrigation, iv antibiotics
• Colostomy repair
• Usually after a period of at least 10 weeks

15
Diverticulosis in Korea

• Characteristics
• Low incidence, but increasing
• Rt colon (over 60) gt Lt colon
• Young Age, Man, Congenital, Solitary, True type,
  Uncomplicated type
• Differential Diagnosis from Acute Appendicitis
• RLQ pain first symptom site, long duration
• Nausea, vomiting absent or low
• Previous appendectomy
• Known diverticulosis (Barium enema, Colonoscopy)
• Fecalith
• Age 3040 year old (later than appendicitis)
• History of lower GI bleeding

16
References

• Sabiston Textbook of Surgery 17ed
• Harrisons Principles of Internal Medicine 16th
• Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS.
  Current management of diverticulitis. Curr Surg.
  2004 Jul-Aug61(4)361-5
• Salem L, Veenstra DL, Sullivan SD, Flum DR. The
  timing of elective colectomy in diverticulitis a
  decision analysis. J Am Coll Surg. 2004
  Dec199(6)904-12.
• Natarajan S, Ewings EL, Vega RJ. Laparoscopic
  sigmoid colectomy after acute diverticulitis
  when to operate? Surgery. 2004 Oct136(4)725-30.
  
• Park JK et al. Clinical analysis of right colon
  diverticulitis. J Korean Surg Soc 2003
  Jan6444-48
• Chang JH et al. Surgical treatment of the colonic
  diverticulosis. J Korean Surg Soc 2002
  May62415-420

17
Thank you for your attentions.