Diverticular disease of the colon.

Diverticulosis:Definition: -Diverticulosis is a condition in which diverticula can be found within the colon, especially the sigmoid; diverticula are actually false diverticula in that only the mucosa and submucosa herniate through the bowel musculature; true diverticula involve all layers of the bowel and are rare in the colon. - In asia they are more common on the right side of the colon - It is due to weakness in the bowel wall which develop at points where nutrients blood vessels enter between antimesenteric and mesenteric taenia; increased intraluminal pressures then cause herniation through these areas.- People with low fiber diets, chronic constipation, obesity and a positive family history are at risk of diverticulosis. The incidence increases with age. There is no gender difference. - signs and symptoms include: Bleeding Massive diverticulitis asymptomatic. (very common) Diagnostic approach: Bleeding: without signs of inflammation: colonoscopy Pain and signs of inflammation: Abdominal/pelvic CT scan - It is safe to get a colonoscopy or barium enema/ sigmoidoscopy 6 weeks after inflammation resolves due to the risk of perforation. It is done to rule out colon cancer. Treatment: -High fiber diet is recommended. Surgery: - Recommendations: Complications of diverticulitis (fistula, obstruction, stricture) Recurrent episodes hemorrhage Suspected carcinoma prolonged symptoms Abscess not drainable by percutaneous approach.Diverticulitis: Definition: - Inflammation/Infection or perforation of a diverticulum. - Pathophysiology: Obstruction of a diverticulum by a fecalith leading to inflammation and microperforation. History Ask about pain (LLQ pain (cramping or steady)) --> SOCRATES change in bowel habits (diarrhea or constipation) Blood in the stool (red, maroon, Black) fever/chills (frequency, type) Yes/ Yes Anorexia/ weight change? Yes (ileus also) LLQ mass Nausea/vomiting Yes/Yes Pain upon urination (Dysuria) Change in urine Dysuria Distended abdomen? What kind of diet? Previous hospitalization Past medical / Family Hx / Medication/ past surgeries Alcohol / smoking/ profession. / allergies - In diverticulosis ask same questions but don't expect systemic findings because no infections.- BLEEDING ONLY IN DIVERTICULOSIS. ( LOWER GI BLEEDING) Physical exam: Check vital signs to see severity of the disease (tachycardia, fever, hypotensive--> signs of sepsis) Abdominal exam DRE- With acute diverticulitis we expect to find: Low grade fever Abdominal distention or asymmetry due to an inflammatory process tenderness localized in LLQ Rebound: percussion, palpation Rule out colon cancer. Hinchey classification: The management of acute diverticulitis is largely dictated by the stage of the disease at presentation: Stage 0 : mild clinical diverticulitis --> treated conservatively with bowel rest and antibiotics for anaerobes and gram negative rods. If young, stable and no co morbidities: do it orally, if older with co morbidities: IV hospitalization. Stage 1a: Inflammation confined to the pericolic region --> above treatmentStage 1b: Presence of pericolic abscess or phlegmonStage 2: Pelvic, retroperitoneal, distant intraperitoneal abscess/ phlegmon --> stage 1b and 2 need percutaneous drainage and antibiotics Stage 3: complicated diverticulitis --> presence of diffuse peritonitis and no communication between bowel and peritoneal cavity. stage 4: feculent peritonitis and communication between bowel and peritoneal cavity --> stage 3 and 4 need emergent surgery.

Laboratory studies: CBC with differential: Increase WBC, hemoglobin and hematocrit for dehydration and anemia Electrolytes and renal studies: for dehydration Urinalysis: for symptoms of UTI to check for colovesicular fistula PT/ PTT, Type and screen studies Beta HCG to rule out pregnancy in women prior to surgery. Imaging: Colonoscopy: Do not do colonoscopy in patient who is acutely ill. We do it to examine the colon and check for 1) diverticulitis and 2) any polyps or colon cancer. Abdominal Xray1. Upright chest Xray: allow us to see the diaphragm and help us detect presence of any free air in the abdomen. 2. Flat abdominal Xray: Show us presence of free air which implies presence of perforation or if there is an ileus or obstruction.3. Upright abdominal Xray Double contrast barium enema : not for acute attack, used as a road map before surgery CT scan of abdomen and pelvis (best test): in acute diverticulitis we see1. Fat stranding 2. bowel thickening 3. extraluminal air4. Swollen, edematous bowel wall; 5. In complicated diverticulitis: fistulas, Abscess, phlegmon. Complications: Abscess, diffuse peritonitis, fistula (most common colovesicular), obstruction, perforation, stricture.Work up: Initial treatment:1. IV fluids2. NPO3. Broad spectrum antibiotics with anaerobic coverage4. NG suction Treatment of diverticular abscess: percutaneous drainage, if not possible --> surgery Surgery warranted if: 1. Obstruction2. fistula3. free perforation 4. abscess not amenable to percutaneous drainage5. sepsis6. deterioration with initial treatment Elective resection: 1. Two episodes of diverticulitis: should be considered after the first episode in a young, diabetic, or immunosupressed patient. Surgery: - Elective surgery: one stage operation --> resection of involved segment and primary anastomosis ( with preop bowel preparation) - Surgery for an acute case of diverticulitis with a complication: Hartmann's procedure with subsequent reanastomosis of colon usually after 2-3 post op monthsPost operative care: Check for bowel movement1. Passage of gas and bowel movement2. Nausea/ vomiting NGT can be removed unless high output is recorded. Advance diet if patient is tolerating it, not having nausea and abdominal distention. Pain control Encourage ambulation and use of incentive spirometer Monitor wound infection, intra abdominal abscess