Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University By: Mohd Syafiq

Bin Shahbudin (06-06-102)

Diverticular Disease
Introduction
Diverticular disease occurs when pouches (diverticula) in the intestine, usually the large intestine or colon, become inflamed. Most diverticula occur in the sigmoid colon, the curved part of the large intestine closest to the rectum, and they tend to become more numerous as we age. This disease is classified either Diverticulosis or Diverticulitis Diverticulosis is the presence of many diverticula along the intestinal wall. It occurs more commonly in countries such as the U.S. where the diet is generally low in fiber. More than 50% of adults over age 60 have diverticula, and 80% have no symptoms. Diverticulitis occurs when one or more diverticula become inflamed. The inflammation may be local (just in the area of the diverticulum), or may spread to the abdominal lining (peritoneum), called peritonitis. Small (microscopic) or large perforations (holes in the intestinal wall) occur in 15 - 20% of people who have diverticula.

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Signs and symptoms

Uncomplicated case: Diverticula usually asymptomatic., If symptoms do appear, they may include the following:

Left lower quadrant pain (70%) Fever and localized tenderness Nausea Vomiting Irregular bowel movements, including constipation or diarrhea Bloating

Complicated/emergent cases: Fistulas, or abnormal passageways from the intestines into the abdomen or to another organ such as the bladder. Bleeding Urinary tract infection, gas in the urine, pain while urinating, or frequent micturition.

Perforation and Peritonitis sudden severe abdominal pain, muscle spasms, guarding (involuntary contraction of muscles to protect the affected area), and possibly sepsis, the term for an infection that has spread to the blood

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Etiology and risk factors

The cause of diverticular disease is still debatable. However, several factors may contribute to change structure of bowel which are mainly aging process, changes in bowel pressure and movement and low dietary fiber intake. These factors below increase the risk of developing diverticular disease:

Low fibre diet Advanced age (more than half of people over age 70 have the condition) Obesity Male gender, for diverticulitis

The following may contribute as well:

High fat intake Lack of regular physical activity

Investigation
LAB Complete blood count The white blood cell count may show leukocytosis and a left shift, but may be normal in immunocompromised, elderly, or less severely ill patients. A hemoglobin level is important in patients who report hematochezia

Urinalysis Urinalysis may reveal red or white blood cells in patients with a colovesicular fistula or with diverticulitis adjacent to the ureters or the bladder A urine culture may distinguish sterile pyuria due to inflammation from polymicrobial infection due to fistula

Liver and Renal Function test

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Renal function is assessed prior to the administration of most intravenous contrast material Liver enzyme and lipase levels may help to exclude other causes of abdominal pain

Others Blood cultures should be obtained prior to the administration of empiric parenteral antimicrobial therapy in patients who are severely ill or in those with complicated disease A pregnancy test must be performed in any female of childbearing age with abdominal pain

Abdomen X-Ray Demonstrate bowel obstruction or paralytic ileus; The presence of free air can indicate bowel perforation

Abdominal CT Computed tomography (CT) scanning of the abdomen is considered the best imaging method to confirm the diagnosis. Sensitivity and specificity, especially with helical CT and colonic contrast, can be as high as 97%. Possible CT findings include the following:

Pericolic fat stranding due to inflammation Colonic diverticula Bowel wall thickening Soft-tissue inflammatory masses Phlegmon Abscesses

Sigmoidoscopy or colonoscopy and barium enema colonoscopy need to be avoid in early case of diverticulosis because if done, this modality may perforate the diverticula.

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Management
Prehospital care Acute abdomen and obvious and occult GI hemorrhage are the clinical scenarios that necessitate prehospital intervention. Vascular access, intravenous fluid, oxygen, and prompt transport to the hospital are all that is required in the field. Medical Abdominal pain without clinical evidence of diverticulitis or intestinal obstruction requires no specific treatment. Patients benefit from the use of bulk-forming agents, such as fiber, bran, and cellulose products. Intractable pain associated with anemia and jejunal loop dilatation on radiograph should heighten concern for jejunal diverticulosis. When diverticula are secondary to small bowel dysmotility, no specific intervention is warranted, other than surgical if complications arise. For uncomplicated diverticulosis, Patient will get benefit from high fibre diet. Fibre keep the stool soft and lower the pressure inside the colon so that the bowel content can move by peristaltic easily. In addition, The American Dietetic Association recommends consuming 20 to 35 gram of fibre each day to improve the bowel habit mainly for this uncomplicated diverticulosis. For diverticulitis, patients often require hospitalization because preoperative diagnosis of small bowel diverticulitis is difficult. Initial interventions include the following:

Bed rest Nothing by mouth and/or nasogastric suctioning

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

IV fluid Broad-spectrum antibiotic coverage such as metronidazole and 3 rd generation cephalosporin. Surgical consultation: Urgent surgery rarely is indicated unless perforation, abscess, or neoplasm is suspected.

Surgical treatment for diverticulitis removes the diseased part of the colon, most commonly, the left or sigmoid colon. Often the colon is hooked up or "anastomosed" again to the rectum. Complete recovery can be expected. Normal bowel function usually resumes in about three weeks. In emergency surgeries, patients may require a temporary colostomy bag. Patients are encouraged to seek medical attention for abdominal symptoms early to help avoid complications.

Management of complication Surgery is reserved for patients with recurrent episodes of diverticulitis, complications or severe attacks when there's little or no response to medication. Surgery may also be required in individuals with a single episode of severe bleeding from diverticulosis or with recurrent episodes of bleeding . GI bleeding or hemorrhage Diverticular bleeding is the source of 17 to 40 percent of lower gastrointestinal (GI) hemorrhage in adults, making it the most common cause of lower GI bleeding," write Thad Wilkins, MD, from Medical College of Georgia in Augusta, and colleagues. The most common presentation of diverticular bleeding is massive, painless rectal hemorrhage. In approximately 80% of patients, diverticular hemorrhage resolves spontaneously. Intravenous fluid replacement should begin with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells if bleeding persists.

Patients with severe bleeding should be treated emergently with resuscitative measures including airway maintenance, supplemental oxygen as needed, measurement of hemoglobin and hematocrit levels, and blood typing and cross-matching.

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Diagnostic workup should begin with colonoscopy, following a rapid bowel preparation with polyethylene glycol solutions so that the procedure can be performed within 12 to 48 hours of presentation. Endoscopic therapeutic maneuvers can be performed if the bleeding source is identified by colonoscopy, such as injection with epinephrine or electrocautery treatment. Endoscopically placed clips (endoclips), fibrin sealant, and band ligation may also be helpful.

For patients in whom colonoscopy does not detect the bleeding source, radionuclide imaging with a technetium-99mtagged red blood cell scan may be helpful

Arteriography may be needed if the lesion is still not identified. Selective embolization, intra-arterial vasopressin infusion, surgery, or other therapeutic modalities should be considered for ongoing diverticular hemorrhage.

nonsurgical techniques to control bleeding have a high success rate, surgery is seldom necessary. However, Indications for surgery include large transfusion requirements (> 4 units of packed red blood cells within 24 hours), recurrent hemorrhage refractory to treatment, or hemodynamic instability despite medical treatment.

Hartmanns procedure which is include resection of rectosigmoid with closure of the rectal stump and formation of an end colostomy.

Directed segmental resection, which requires that the bleeding source be identified before surgery, is the surgical procedure of choice. Subtotal colectomy should be performed only in patients with uncontrolled, massive, nonlocalized lower GI bleeding refractory to other interventions, because of high morbidity (37%) and mortality rates (11% - 33%).

To prevent the progression of diverticular disease, fibre supplementation (32 g/day) and increasing levels of physical activity may be helpful.

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

Intestinal perforation Early surgery resection which is widely perform now is Hartmanns procedure that include temporary colostomy is the treatment of choice. Fluid and electrolyte management as well as antibiotics are essential adjuncts. Intestinal obstruction Initial management is similar to uncomplicated diverticulitis. Urgent surgical consultation is mandatory. Intestinal pseudo-obstruction Cautious conservative management is indicated while excluding mechanical obstruction. Fistula formation This is a rare complication. Mal-absorption This is often a complication of bacterial overgrowth resulting from blind loop syndrome. It usually responds to antibiotics. Flatulence and bloating These are another complication of bacterial overgrowth, which usually responds to antibiotic therapy such as metronidazole, fluoroquinolone, 2 nd and 3rd generation cephalosporin.

References
1. http://emedicine.medscape.com/article/185356-treatment 2. http://www.medscape.org/viewarticle/712238 3. http://www.umm.edu/altmed/articles/diverticular-disease-000051.htm 4. http://www.fascrs.org/patients/conditions/diverticular_disease/ 5. http://www.healthecare.us/category/diverticulitis

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Emergency Unit, General Surgery International Undergraduate Medical Program Faculty of Medicine, Alexandria University

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