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Diverticular Disease
Dr. Matt W. Johnson
Introduction & Overview
• Pathology• Physiology• Location• Complications
– Bleeding– Obstruction– Fistula– Acute Diverticulitis
• Management of Acute Diverticulitis
Pathology
• Congenital• Acquired
– association with Western diets high in refined carbohydrates and low in dietary fibre1
– Deficiency of vegetable fibre in diet2
– Disordered motility– Hyperelastosis may lead to structure change– Collagen abnormalities– Age
• Diverticular disease occurs in over 25% of the population, increasing with age3
1 Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005
Physiology
• La Place effects• High intra-luminal pressure• Resultant characteristic protrusion mucosa• Worst at terminal arterial branches • Rectal sparing
– ?due to complete layer of longitudinal muscle and large diameter
Physiology and Anatomy
•Terminal arterial branches
•Penetrate circular muscle
•Often lie adjacent to taenia
Location
• Classically Sigmoid• In Orient often right-sided• Rectal Sparing
• Can occur anywhere(but considered separately)e.g. Small bowel –see later
Right vs. Left
Complications
• Obstruction• Bleeding• Inflammation “itis”
– Fistula – Sepsis– Perforation
• May co-exist with IBD
Specimen showing blood in diverticulae
Obstruction in Diverticular Disease
• Progressive distension
• Single contrast enema will delineate this
• Often present like cancer
• Diagnosis – often only at operation (opened specimen) or – on histology
Bleeding in Diverticular Disease
• Rarely exsanguinating• Often requires repeat transfusion• Consider mesenteric angiography if available
– Embolisation (risk of ischaemia and infarction)– Allows targeted resection
• Operative intervention uncommon– On table colonoscopy– Exclusion
Re-Bleeding Rates
Re-bleeding rateYear Percentage
1 9
2 10
3 19
4 25
1 Longstreth Am J Gastro 1997
Other Causes Of Colonic Bleeding
• Exclude–IBD–Neoplasm–Angiodysplasia–Ischaemic colitis–Radiation proctitis– Varices
Fistula
• Abnormal connection• Commonest communications are
– Colovesical– Colovaginal (esp if prev TAH)
• Colovesical Symptoms– Pneumaturia– Recurrent infections– Faecalent urine or particulates
• Diagnosis of site/communication vs pathology– CD/CRC/TCC
Acute Diverticulitis
• Abscess– Peridiverticular– Mesenteric– Pericolic
• Perforation– Concealed– Free
• Peritonitis (gangrenous sigmoididits)– Purulent or serous or faecal– Local or generalised or pelvic
1 Killingback Surg Clin North Am 1983
Emergency Presentation
• Symptoms– Generally unwell– Pain localising to left iliac fossa*– Abdominal distension– Altered bowel habit e.g. diarrhoea– Nausea/Fever
• Signs– LIF tenderness– *Beware RIF pain-in right sided diverticulitis and
where sigmoid crosses midline– Systemic signs (T/HR/BP/WCC)– May be palpable on pR at anterior rectal wall
Management
• Resuscitation• Analgesia• Bloods• ECG/Catheter/Urine• Rectal examination (+/-sigmoidoscopy)• CXR• AXR• USS• CT Scan• Operative intervention
CXR
AXR
Diverticular disease
CT Scan
Perforated diverticulitis of the sigmoid colon-CT
Diverticulitis with pericolic abscess
Operative Picture
Perforation
Operative considerations
• Serial assessment and clinical judgement – (even if Radiological perforation)
• Operative indications– generalized peritonitis– uncontrolled sepsis,– visceral perforation– acute clinical deterioration
• At operation– Resection better than no resection1
– Hartmann’s vs anastomosis
1 Krukowski & Matheson Br J Surg 1984
Anastomosis
• Is there any role for primary anastomosis in the inflamed bowel?
• Consider if fully resuscitated and colorectal Surgeon• Retrograde gun/washout kit• Schilling et al. 2001 Diseases of the Colon and Rectum
– diverticulitis with peritonitis – 13 patients one stage– 42 Hartmann’s procedure– 7% mortality in both groups
• Similar complication rates– Not a study of bowel obstruction
Elective Presentation
• Via outpatients• Often milder version of emergency
presentation• Incidental radiological finding
– AXR– Contrast study e.g. Barium Enema– CT scan
• Rarely if insiduous, an abscess may be found on Barium Enema as an outpatient
Elective resection for Diverticultis
• After recovering from an episode of diverticulitis the individual risk of an urgent Hartmann’s is 1 in 2000 patient-years of follow-up.
• Surgery for diverticular disease has a high complication rate
• 25% of patients have ongoing symptoms after bowel resection (IBS/IBD)
• No evidence to support the idea that elective surgery should follow two attacks of diverticulitis.
• Further prospective trials are required.1 Janes et al BJS 2005
Duodenal and Jejunal Diverticulosis
• Separate from colonic diverticulosis. • Most occur in the jejunum and occasionally duodenum. • Jejunal diverticula are acquired protrusions of the
mucosal lining through the muscular wall of the bowel. • Encourages particular bacterial overgrowth. • A combination of alteration of the intraluminal contents
by these bacteria may result in malabsorption – Calcium– Iron– Vitamins D or B12.
• Patients may present with anaemia and occasionally osteomalacia.
Proximal Jejunal Diverticulitis
Incidental Jejunal Diverticular
Proximal Jejunal diverticulitis with perforation
Questions
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