Diverticulitis

Diverticulitis
Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center
Barcelona - Gaudi
Diverticulitis
Outline Definition Pathophysiology Epidemiology Clinical presentation Differential Imaging Laboratory Treatment Reasons for surgery
Diverticulitis
Definition
Diverticula
Etiology
Outpouchings
Occur in areas weak and under stress Prolapse of mucosa and submucosa may occur.
Location
Arteries penetrate the muscularis to reach the submucosa and mucosa. Diverticula form through entire colon Left colon Sigmoid (most common) Right sided (uncommon)
http://health-pictures.com/diverticulitis-picture.htm
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecils Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Definition
Diverticulitis
Fecalith becomes impacted in a diverticulum Erosion through the serosa

Perforation
Citadel Park
Diverticulitis
Pathophysiology
Diverticula
Acquired or congenital Can affect small or large intestine May be related to an increase in intramural pressure Occurs in the weakest areas of the colonic wall
Adjacent to the vasa recta Mesenteric side of the colon
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
Diverticulitis
Pathophysiology
Theories
Deficiency in dietary fiber
Western diet Decreased fecal bulk Narrowing of the colon Small fecal mass Increased intraluminal pressure needed to move material
Loss of tensile strength Decrease in elasticity
Proof?
High fiber diet appears to decrease incidence
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Diverticulitis
Pathophysiology
Diverticula
False diverticula (pulsion)
Herniation through colonic wall
Mucosa Muscularis
Occur between tenia coli

Points of weakness
High intraluminal pressure Bleeding is self limiting
True diverticula
Rare and usuall congenital Comprise all layers of bowel wall
Diverticulitis
Pathophysiology Diverticulitis
Inflammation in and around a diverticulum Stagnation of nonsterile inspissated fecal material (fecalith)
May compromise the blood supply Cusing inflammatory erosion of the mucosal lining Perforation
Intramural abscess Fibrinous exudate Abscess formation Local adhesions Peritonitis Sealed-off abscesses Contained sinus tracts Fistulas
La Familia
Diverticulitis
Epidemiology
Frequency in US
Diverticular disease
5% of population at age 40 33-50% of population older than 50 80% of population older than 80
Diverticulitis
10-20% of patients with diverticular disease
Frequency internationaly
Diverticulosis occurs in 0.2% of population
Diverticulitis
Epidemiology
Mortality and Morbidity

20% require surgical therapy Mortality rate of 7.7% (if peritonitis is present)
Race
Asians predisposed to right sided diverticulitis
Sex
No relationship
Age
Disease increases with age
Diverticulitis
Clinical Manifestations
Symptoms
Pain
Typically located in left lower quadrant Subacute and constant pain Right sided diverticulitis can occur (congenital?)
Fever
Almost invariably present High-grade fever and sepsis
If perforation is not contained or When the peritonitis is generalized
Constipation or loose stools may be reported Rectal bleeding is unusual.

Diverticulitis
Clinical Manifestations
Fistulas occur in 5% of patients w/ complicated diverticulitis

Colovesical Colovaginal Coloenteric
Diverticulitis
Differential Diagnosis
Lower abdominal pain, fever, and bloody diarrhea
Bacterial colitis (Shigella, Salmonella, Campylobacter) Ischemic colitis Inflammatory bowel disease
Acute severe abdominal pain
Perforation of an abdominal viscus
Peptic ulcer Small bowel obstruction Choledocholithiasis Nephrolithiasis Rupture and dissection of an abdominal aortic aneurysm Intestinal ischemia Cholecystitis Pancreatitis Diverticulitis Crohn's disease Appendicitis Cholecystitis Pancreatitis Intestinal ischemia Inflammatory disorders
Subacute onset of pain

Generalized peritonitis
Acute abdomen
Pain of a constant nature

Gynecologic disorders
May be localized to the left lower quadrant (LLQ)

Colicky pain occurs

Nephrolithiasis Intestinal obstruction

Pancreatitis Peptic ulcer disease Biliary tract disease Diaphragmatic irritation
Radiation of pain
Shoulder pain
Significant vomiting is seen with pancreatitis or obstruction of the stomach or small bowel.
Diverticulitis
Laboratory
Leukocytosis
Common, nonspecific
Urinalysis
Protein or rare white blood cells may be found
Nonspecific
Fecal leukocytes
Should be sought if diarrhea is present
Candy Factory
Diverticulitis
Imaging
Abdominal radiographs
May indicate
A displaced colon Extraluminal gas Colonic mucosal abnormalities
More helpful in excluding other potential causes of left lower quadrant pain.
Diverticulitis
Imaging
Abdominal CT
Test of choice May demonstrate
Bowel wall thickening Abscess formation Diverticula
Diagnostic barium enema

Safe when carefully performed Findings include
Spiculation of the mucosa Spasm Frank perforation Abscess
Findings specific for diverticulitis, but may be hard to distinguish from carcinoma
CT and barium enema are complementary

Neither is 100% sensitive or specific.
Diverticulitis
Imaging
Computed tomographic scan

Marked thickening of
Distal end of the descending colon
Inflammatory changes (straight arrow) Extraluminal gas (curved arrow)
Diverticulitis
Imaging
Barium Enema
Colon with sinus formation Shows multiple diverticula Communicating sinus is clearly seen (arrow).
Diverticulitis
Imaging
Endoscopic examination
Contraindicated with diverticulitis Theoretical potential to exacerbate perforation Can detect diverticulosis before or between attacks
Sigmoidoscopy
Appropriate when
Carcinoma or Inflammatory bowel disease is highly suspected
Diverticulitis
Imaging
Colonoscope
Wide-mouthed openings to diverticula Colonoscopy may be difficult and hazardous when diverticula are large enough to admit the tip of the scope.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
Street entertainers
Diverticulitis
Treatment
Mild diverticulitis
Initially (symptoms usually disappear rapidly)
Rest A liquid diet Oral antibiotics
After a few days

Soft, low-fiber diet and take a daily psyllium (i.e. metamucil) seed preparation.
After 1 month
A high-fiber diet can be started
Severe symptoms (perforation, peritonitis)

Admitted to hospital Intravenous fluids and antibiotics Bedrest Nothing by mouth until the symptoms subside
About 20% of people who have diverticulitis require surgery because the condition does not improve.
Diverticulitis
Treatment Inpatient
Broad-spectrum antibiotics
Third-generation cephalosporin
Ceftriaxone 1.5mg intravenously daily
Anaerobic coverage
Metronidazole 250mg intravenously three times daily
At discharge
Oral antibiotics to complete 14 day course Ciprofloxacin and Metronidazole)
Outpatient (mild disease)

Oral antibiotics (14 days)
Ciprofloxacin (500mg twice daily) Metronidazole (250mg three times daily) for 14 days
Bowel rest
Diverticulitis
Treatment
Colon carcinoma may mimic diverticulitis

Colonoscopy or sigmoidoscopy is recommended 4-6 weeks after recovery when surgery is not performed
Diverticulitis
Treatment
Early surgical consultation is important

Especially in the presence of significant pain or An acute abdomen
Percutaneous catheter drainage

If large abcess is present
Temporary
Diverticulitis
Treatment
Some reasons for surgery

Colonic stricture Bleeding Fistula formation to
The small bowel Colon Bladder Vagina
Surgcial resection
Warranted in reoccurrences (1/3 of all patients) Sigmoid colectomy with anastamosis
Diverticulitis
Treatment
Hinchey staging
Stage I
Colonic inflammation Pericolic abcess
Percutaneous drainage? If not.

Sigmoid colectomy w/ primary anastamosis
Stage I or II
Stage II
Colonic inflammation Retroperitoneal or Pelvic abcess
Stage III
Purulent peritonitis
Sigmoid colectomy w/ hartman pouch

Larger abcesses
Stage IV
Fecal peritonitis
Festivals
Diverticulitis
Reasons for Elective Surgery
CONDITION 1. Two or more severe attacks of diverticulitis (or one severe attack in someone younger than 50) 2. Narrowing of the sigmoid colon (lower part of the large intestine) due to scarring 3. Persistent tender mass in the abdomen 4. X-ray showing suspicious changes in the sigmoid colon 5. Pain when urinating REASON 1. High risk of serious complications 2. High risk of serious complications 3. May be cancer 4. May be cancer 5. May be a warning of impending fistula formation between the large intestine and the bladder 6. Large intestine may have ruptured into the abdominal cavity
6. Sudden abdominal pain in people taking corticosteroids
Any questions?

Diverticulitis

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Diverticulitis

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Diverticulitis

Fecalith becomes impacted in a diverticulum Erosion through the serosa

Loss of tensile strength Decrease in elasticity

Occur between tenia coli

High intraluminal pressure Bleeding is self limiting

Mortality and Morbidity

Constipation or loose stools may be reported Rectal bleeding is unusual.

Fistulas occur in 5% of patients w/ complicated diverticulitis

Subacute onset of pain

Pain of a constant nature

Colicky pain occurs

Nephrolithiasis Intestinal obstruction

Diagnostic barium enema

CT and barium enema are complementary

Computed tomographic scan

Inflammatory changes (straight arrow) Extraluminal gas (curved arrow)

After a few days

Severe symptoms (perforation, peritonitis)

Outpatient (mild disease)

Colon carcinoma may mimic diverticulitis

Early surgical consultation is important

Percutaneous catheter drainage

Some reasons for surgery

Percutaneous drainage? If not.

Sigmoid colectomy w/ hartman pouch

6. Sudden abdominal pain in people taking corticosteroids

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