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M E N G D A Z H A N G , J M S

Management of Diverticulitis

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Case

HPI: 47 yo female with hx of HTN and diabetes c/opersistent right abdominal pain that has worsenedsince last November.

- diagnosed with diverticulosis in 2005 by colonoscopy.Also showed small ventral hernia and bilateral ovarian cysts

- 4 hospitalizations with IV antibiotic treatment sinceNovember 2013

- Pain has become more constant, does not radiate. Pain is

worsened after a meal.

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Case

Past Surgical Hx

Cesarean section

Hysterectomy

Open cholecystectomy

PMH/Meds

HTN: takes furosemide, beta blockers, olmesartan

Diabetes Mellitus: managed with insulin

Asthma: managed with fluticasone, Tiotropium Back pain: Percocet

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CT Scan 7/25

Patient CT

Diverticulitis

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Pre-op Labs

B-hCG pregnancy test: negative

Metabolic Panel: wnl except for elevated glucose(250mg/dl)

CBC with differential: wnl WBC count: 7.0

Colonoscopy: confirms diffuse diverticulosis.Negative for masses or polyps

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Physical Exam

Abdomen: Soft, slight right sided tenderness to deeppalpation, non-distended. Well healed rightsubcostal and low midline scars.

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Diagnosis/Treatment

Recurrent chronic right-sided diverticulitis treatedwith IV antibiotics during acute episodes.

After discussing risks and benefits of surgery, patientunderwent elective right hemicolectomy withprimary anastomosis.

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Post-Op

No complications

POD2, WBC count elevated to 15.4; Normalizedwithin next 2 days

d/c home on POD #5 after return of bowel functionand able to tolerate soft diet

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Diverticular Disease

Diverticula are small mucosal herniations in the GItract, usually occurring where the intestinal wall is

weak like where the vasa recta penetrates the wall

Seen in >65% of patients over 85 years old.

Causes: low fiber diet, constipation, obesity

Sigmoid colon is most common location in caucasians. Rightsided disease more common in Asia

Diverticulitis= inflammation of diverticula. 15% of patients

with diverticulosis develop diverticulitis

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Right Sided Diverticulitis

Location: cecum, ascending colon, transverse colon

Common in Asian population (52% vs 49%). Can becongenital

Patients w R sided disease were younger Hemicolectomy was more common for right sided

disease, and had lower rate of operativecomplications

Symptoms mimic appendicitis

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Management of Diverticulitis

Non-surgical: antibiotic therapy, diet changes, OTCanalgesics. Percutaneous drainage of abscess, usuallyfollowed by resection

Surgical: colon resection with primary anastomosisor Hartmanns procedure Emergent surgery in complicated diverticulitis=

perforated diverticula

Indications: hemodynamic instability, diffuse peritonitis, ordiverticulitis refractory to conventional therapy

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Treating Uncomplicated vs. Complicated

Uncomplicated Diverticulitis:

Colon resection with primary anastomosis with recurrentdisease

Complicated Diverticulitis (rupture/perforation)

For stable patients: IV antibiotics. Schedule surgery

For unstable patients: emergency colon resection followed by

primary anastomosis or Hartmanns procedure Hinchey Classification

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Hinchey Classification

I - localized abscess

II - pelvic abscess Abscess >5cm should be drained

III - purulent peritonitis

IV - feculent peritonitis

Hinchey I, II can be treated conservatively (abx, soft

diet) Hinchey III, IV are associated with high mortality, so

surgical intervention is favored

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Elective Colectomy for Diverticulitis

2000 ASCRS Practice Parameters: electivecolectomies were performed after 2 episodes ofuncomplicated diverticulitis to prevent futurecomplications

2014 ASCRS Practice Parameters: individualizeddecision for elective resection. recommends against

prophylactic colectomies for uncomplicateddiverticulitis

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Addressing the Appropriateness of Elective ColonResection for Diverticulitis (2014)

Most emergency colectomies for diverticulitis occur at theinitial hospitalization

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Sources

Li D, de Mestral C, Baxter NN, McLeod RS, Moineddin R, Wilton AS,Nathens AB. Risk of Readmission and Emergency Surgery FollowingNonoperative Management of Colonic Diverticulitis. Annals of Surgery.2014; 260:3

Simianu VV, Bastawrous AL, Billingham RP, Farrokhi ET, Fichera A,

Herzig DO, Johnson E, Steele SR, Thirlby RC, Flum DR. Addressing theAppropriateness of Elective Colon Resection for Diverticulitis: A ReportFrom the SCOAP CERTAIN Collaborative. Annals of Surgery. 2014; 260:3pg533-9

Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment ofsigmoid diverticulitis. Dis Colon Rectum. 2014;57:284294.

Oh HK et al. Surgical management of colonic diverticular disease:Discrepancy between right- and left-sided diseases.World JGastroenterol.2014 Aug 7;20(29):10115-20

http://www.ncbi.nlm.nih.gov/pubmed/25110438http://www.ncbi.nlm.nih.gov/pubmed/25110438http://www.ncbi.nlm.nih.gov/pubmed/25110438http://www.ncbi.nlm.nih.gov/pubmed/25110438http://www.ncbi.nlm.nih.gov/pubmed/25110438http://www.ncbi.nlm.nih.gov/pubmed/25110438

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Thank you!