Diverticular Disease of the Colon

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Diverticular Disease of the Colon

• Jason Phillips, MD

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Diverticulosis and the Simpsons
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Nomenclature

• Diverticulum sac-like protrusion of the colonic
  wall
• Diverticulosis describes the presence of
  diverticuli
• Diverticulitis inflammation of diverticuli

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Epidemiology

• Before the 20th century, diverticular disease was
  rare
• Prevalence has increased over time
• 1907 First reported resection of complicated
  diverticulitis by Mayo
• 1925 5-10
• 1969 35-50

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Epidemiology

• Increases with age
• Age 40 lt5
• Age 60 30
• Age 85 65

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Epidemiology

• Gender prevalence depends on age
• MgtgtF Age less than 40
• M gt F Age 40-50
• F gt M Ages 50-70
• FgtgtM Ages gt 70

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Anatomic location of diverticuli varies with the
geographic location

• Westernized nations (North America, Europe,
  Australia) have predominantly left sided
  diverticulosis
• 95 diverticuli are in sigmoid colon
• 35 can also have proximal diverticuli
• 4 have only right sided diverticuli

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Anatomic location of diverticuli varies with the
geographic location

• Asia and Africa diverticulosis in general is rare
  and usually right sided
• Prevalence lt 0.2
• 70 diverticuli in right colon in Japan

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What exactly is a diverticulum?

• Colonic diverticulosis is actually not a true
  diverticulum but rather a pseudo-diverticulum

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What exactly is a diverticulum?

• True diverticulum contains all layers of the GI
  wall (mucosa to serosa)
• Colonic pseudo-diverticulum more like a local
  hernia
• Mucosa-submucosa herniates through the muscle
  layer (muscularis propria) and then is only
  covered by serosa

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Pathophysiology

• Diverticuli develop in weak regions of the
  colon. Specifically, local hernias develop where
  the vasa recta penetrate the bowel wall

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Mucosa
Submucosa
Muscularis
Vasa recta
Serosa
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Pathophysiology

• Law of Laplace P kT / R
• Pressure K x Tension / Radius
• Sigmoid colon has small diameter resulting in
  highest pressure zone

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Pathophysiology

• Segmentation motility process in which the
  segmental muscular contractions separate the
  lumen into chambers
• Segmentation ? increased intraluminal pressure ?
  mucosal herniation ? Diverticulosis
• May explain why high fiber prevents diverticuli
  by creating a larger diameter colon and less
  vigorous segmentation

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Lifestyle factors associated with diverticular
disease

• Low fiber ? diverticular disease
• Not absolutely proven in all studies but strongly
  suggested
• Western diet is low in fiber with high prevalence
  of diverticulosis
• In contrast, African diet is high in fiber with a
  low prevalence of diverticulosis

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Lifestyle factors associated with diverticular
disease

• Obesity associated with diverticulosis
  particularly in men under the age of 40
• Lack of physical activity

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Uncomplicated diverticulosis

• Usually an incidental finding at time of
  colonoscopy

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Uncomplicated diverticulosis

• Considered asymptomatic
• However, a significant minority of patients will
  complain of cramping, bloating, irregular BMs,
  narrow caliber stools
• IBS?
• Recent studies demonstrate motility abnormalities
  in pts with symptomatic uncomplicated
  diverticulosis

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Uncomplicated diverticulosis

• Treatment Fiber
• Bulk content reduces colonic pressure preventing
  underlying pathophysiology that lead to
  diverticulosis
• 20 to 30 g fiber per day is needed difficult to
  get with diet alone

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Do patients need to avoid foods with seeds or
nuts?
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NO! That is a myth.
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Diverticulitis

• Diverticulitis inflammation of diverticuli
• Most common complication of diverticulosis
• Occurs in 10-25 of patients with diverticulosis

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Pathophysiology of Diverticulitis

• Micro or macroscopic perforation of the
  diverticulum ? subclinical inflammation to
  generalized peritonitis
• Previously thought to be due to fecaliths causing
  increased diverticular pressure this is really
  rare

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Pathophysiology of Diverticulitis

• Erosion of diverticular wall from increased
  intraluminal pressure ? inflammation ? focal
  necrosis ? perforation
• Usually inflammation is mild and microperforation
  is walled off by pericolonic fat and mesentery

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Diagnosis of Diverticulitis

• Classic history increasing, constant, LLQ
  abdominal pain over several days prior to
  presentation with fever
• Crescendo quality each day is worse
• Constant not colicky
• Fever occurs in 57-100 of cases
• In one study, less than 17 of pts with
  diverticulitis had symptoms for less than 24
  hours

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Diagnosis of Diverticulitis

• Previous of episodes of similar pain
• Associated symptoms
• Nausea/vomiting 20-62
• Constipation 50
• Diarrhea 25-35
• Urinary symptoms (dysuria, urgency,
  frequency) 10-15

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Diagnosis of Diverticulitis

• Right sided diverticulitis tends to cause RLQ
  abdominal pain can be difficult to distinguish
  from appendicitis

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Diagnosis of Diverticulitis

• Physical examination
• Low grade fever
• LLQ abdominal tenderness
• Usually moderate with no peritoneal signs
• Painful pseudo-mass in 20 of cases
• Rebound tenderness suggests free perforation and
  peritonitis
• Labs Mild leukocytosis
• 45 of patients will have a normal WBC

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Diagnosis of Diverticulitis

• Clinically, diagnosis can be made with typical
  history and examination
• Radiographic confirmation is often performed
• Rules out other causes of an acute abdomen
• Determines severity of the diverticulitis

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Treatment of Diverticulitis

• Complicated diverticulitis Presence of
  macroperforation, obstruction, abscess, or
  fistula
• Uncomplicated diverticulitis Absence of the
  above complications

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Uncomplicated diverticulitis

• Bowel rest or restriction
• Clear liquids or NPO for 2-3 days
• Then advance diet
• Antibiotics

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Uncomplicated diverticulitis

• Antibiotics
• Coverage of fecal flora
• Gram negative rods, anaerobes
• Common regimens
• Cipro Flagyl x 10 days
• Augmentin or Unsayn x 10 days

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Uncomplicated diverticulitis

• Monitoring clinical course
• Pain should gradually improve several days
  (decrescendo)
• Normalization of temperature
• Tolerance of po intake
• If symptoms deteriorate or fail to improve with 3
  days, then Surgery consult

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Uncomplicated diverticulitis

• After resolution of attack ? high fiber diet with
  supplemental fiber

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Uncomplicated diverticulitis

• Follow-up Colonoscopy in 4-6 weeks
• Flexible sigmoidoscopy and BE reasonable
  alternative
• Purpose
• Exclude neoplasm
• Evaluate extent of the diverticulosis

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Prognosis after resolution

• 30-40 of patients will remain asymptomatic
• 30-40 of pts will have episodic abdominal cramps
  without frank diverticulitis
• 20-30 of pts will have a second attack

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Prognosis after resolution

• Second attack
• Risk of recurrent attacks is high (gt50)
• Some studies suggest a higher rate (60) of
  complications (abscess, fistulas, etc) in a
  second attack and a higher mortality rate (2x
  compared to initial attack)
• After a second attack ? elective surgery

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Prognosis after resolution

• Some argue in the elderly recurrent attacks can
  be managed with medications
• Some argue elective surgery should be considered
  after a first attack in
• Young patients under 40-50 years of age
• Immunosuppressed

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Complicated Diverticulitis

• Peritonitis
• Resuscitation
• Antibiotics
• Ampicillin Gentamycin Metronidazole
• Imipenem/cilastin
• Zosyn
• Emergency exploration
• Mortality 6 purulent peritonitis and 35 fecal
  peritonitis

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Complicated Diverticulitis Abscess

• Occurs in 16 of patients with acute
  diverticulitis
• Percutaneous drainage followed by single stage
  surgery in 60-80 of patients

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Complicated Diverticulitis Abscess

• CT guided drain
• Leave in until drain output less than 10 mL in 24
  hours
• May take up to 30 days
• Catheter sinograms helpful to show persistent
  communication between abcess and bowel

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Complicated Diverticulitis Abscess

• Small abscesses too small to drain percutaneously
  (lt 1cm) can be treated with antibiotics alone
• These pts behave like uncomplicated
  diverticulitis and may not require surgery

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Complicated Diverticulitis Fistulas
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Complicated Diverticulitis Fistulas

• Occurs in up to 80 of cases requiring surgery
• Major types
• Colovesical fistula 65
• Colovaginal 25
• Coloenteric, colouterine 10

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Complicated Diverticulitis Fistulas - Symptoms

• Passage of gas and stool from the affected organ
• Colovesical fistula
• pneumaturia, dysuria, fecaluria
• 50 of patients can have diarrhea and passage of
  urine per rectum

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Complicated Diverticulitis Fistulas

• Diagnosis
• CT thickened bladder with associated colonic
  diverticuli adjacent and air in the bladder
• BE direct visualization of fistula track only
  occurs in 20-26 of cases
• Flexible sigmoidoscopy is low yield (0-3)
• Some argue cystoscopy helpful

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Complicated Diverticulitis Treatment of Fistulas

• Surgery
• Resection of affected colon (origin of the
  fistula)
• Fistula tract can be pinched off most of the
  time
• Suture closure for larger defects
• Foley left in 7-10 days

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Surgical Treatment of Diverticulitis

• Elective single stage resection is ideal, 6
  weeks after episode
• Two stage procedure (Hartmann procedure)

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Surgical Treatment of Diverticulitis

• Two stage procedure (Hartmann procedure)
• Sigmoid resection
• Colostomy
• Rectal stump
• 3 months later ? colostomy takedown and
  colorectal anastomosis

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Diverticular bleeding

• Most common cause of brisk hematochezia (30-50
  of cases)
• 15 of patients with diverticulosis will bleed
• 75 of diverticular bleeding stops without need
  for intervention

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Diverticular bleeding

• Patients requiring less than 4 units of PRBC/ day
  ? 99 will stop bleeding
• Risk of rebleeding ? 14-38
• After second episode of bleeding, risk of
  rebleeding ? 21-50

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Diverticular bleeding Pathophysiology

• Diverticulum herniates at site of vasa recta
• Over time, the vessel becomes draped over the
  dome of the diverticulum separated only by mucosa
• Over time, there is segmental weakening of the
  artery ? ruptures and bleeds

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Diverticular bleeding Pathophysiology
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Diverticular bleeding Pathophysiology
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Diverticular bleeding Symptoms

• Most only have symptoms of bloating and diarrhea
  but no significant abdominal pain
• Painless hematochezia
• Start stop pattern water faucet
• Diverticulitis rarely causes bleeding

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Diverticular bleedingManagement

• Resuscitation
• Localization
• Supportive care with blood products

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Diverticular bleeding Localization

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

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Diverticular bleedingLocalization

• Colonoscopy after rapid prep
• Can localize site of bleeding
• Offers possible therapeutic intervention
  (cautery, clip, etc)
• Often limited by either brisk bleeding obscuring
  lumen OR no active bleeding with clots in every
  diverticuli

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Diverticular bleedingManagement
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Diverticular bleeding Localization

• Tagged red blood cell scan
• Can localize bleeding source
• 97 sensitivity
• 83 specificity
• 94 PPV
• Can detect bleeding as slow as 0.1 mL/min
• Often not particularly helpful

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Diverticular bleeding Localization

• Angiography
• Accurate localization
• 30-47 sensitive
• 100 specific
• Need brisk active bleeding 0.5-1 mL/min
• Offers therapy embolization, vasopressin
• 20 risk of intestinal infarction

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Diverticular bleeding Surgery

• Surgery
• Segmental resection
• If site can be localized
• Rebleeding rate of 0-14
• Subtotal colectomy
• Rebleeding rate is 0
• High morbidity (37)
• High mortality (11-33)

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Questions?