Diverticular Disease

OverviewA diverticulumdiverticulum is an abnormal sac or pouch protrudin

g from the wall of a hollow organ.• Diverticula ; pouches• Diverticulosis ; condition of having diverticula

DiverticulosisDiverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution.• Decreased consumption of unprocessed cereals along wit

h 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.

Pathogenesis Diverticula are actually herniations of m

ucosa through the colon at sites of penetration of the muscular wall by arterioles• On the mesenteric side of the antimesenteri

c teniae Sigmoid colon

• The most common site (50%)• The smallest luminal diameter.• Low fiber diet

-> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall

Diverticular bleedingThe most common cause of hematochezia in patient

s over the age of 60• 20% of patients with diverticulosis will have GI bleeding.

Risk factor ; HT, Artherosclerosis, NSAIDUsually self limited, but rebleeding risk (25%)Localization ; Colonoscopy, AngiographySurgery

• Unstable hemodynamics, 6-unit bleed within 24 hr• Without localization ; Total colectomy

DiverticulitisDefinition

• 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, b

ack• Bowel habit change, Anorexia, Fever, Chill, Urinary

urgency

DiverticulitisPhysical 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 e

xam

DiverticulitisDiagnostic Tests

• CT The preferred test to confirm the suspected diagnosis Location of infection, extent of inflammatory process, p

resence and location of an abscess, secondary complications

sigmoid diverticula, thickened colonic wall >4 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 o

f feces through the perforated diverticulitis

Uncomplicated DiverticulitisDisease not associated with free intraperitoneal perf

oration, fistula formation, or obstructionNonoperative treatment

• Bowel rest + Antibiotics ; 75% response• Trimethoprim/sulfamethoxazole or ciprofloxacin and metro

nidazole ; 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

Uncomplicated DiverticulitisInvestigative studies

• After the symptoms have subsided for at least 3 weeks• To establish the presence of diverticula and to exclude ca

ncer, which can mimic diverticulitis• Colonoscopy > Barium enema

Recurrent disease• Second attack (<25%) -> Third attack (>50%)• Elective resection

After infection control ; usually 4 to 6 weeks after the episode Laparoscopic resection ; growing trend Immunocompromised patient : after single attack

Complicated DiverticulitisHinchey classification

• Stage I: Pericolic or mesenteric abscess

• Stage II: Walled-off pelvic abscess

• Stage III: Generalized purulent peritonitis

• Stage IV: Generalized fecal peritonitis

Complicated Diverticulitis Abscess

Usually confined to the pelvis Significant pain, fever, and le

ukocytosis More than 2cm ; should be d

rained• Percutaneous or transanal > la

parotomy Elective surgery ; after 6week

s following drainage• Complete removal of the entire

abnormally thickened bowel

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, CystoscopyTreatment

• Initial treatment ; infection control and reduce the associated inflammation

• Rarely a cause for emergency surgery• Diagnostic steps such as coloscopy should be taken to co

nfirm the cause of the fistula before a definitive operation is undertaken.

Generalized Peritonitis Mechanism

• Perforation without sealing by the body’s normal defenses -> contaminated with feces

• Abscess burst into the unprotected peritoneal cavity -> contaminated with enteric bacteria

Immediate operative intervention• Excise the segment of colon containing perforation and c

onstruct a colostomy using noninflammed colon• Peritoneal cavity irrigation, iv antibiotics

Colostomy repair• Usually after a period of at least 10 weeks

Diverticulosis in KoreaCharacteristics

• Low incidence, but increasing• Rt colon (over 60%) > Lt colon • Young Age, Man, Congenital, Solitary, True type, Uncompli

cated typeDifferential 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 ; 30~40 year old (later than appendicitis)• History of lower GI bleeding

References Sabiston Textbook of Surgery 17ed Harrison’s Principles of Internal Medicine 16th Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current mana

gement of diverticulitis. Curr Surg. 2004 Jul-Aug;61(4):361-5 Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of el

ective colectomy in diverticulitis: a decision analysis. J Am Coll Surg. 2004 Dec;199(6):904-12.

Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate? Surgery. 2004 Oct;136(4):725-30.

Park JK et al. Clinical analysis of right colon diverticulitis. J Korean Surg Soc 2003 Jan;64:44-48

Chang JH et al. Surgical treatment of the colonic diverticulosis. J Korean Surg Soc 2002 May;62:415-420

Thank you for your attentions.