diverticulitis robert zaid pgy-1 october 24, 2005 genesys regional medical center

Diverticulitis

Robert Zaid PGY-1

October 24, 2005

Genesys Regional Medical Center

Barcelona - Gaudi

DiverticulitisOutline

• Definition• Pathophysiology• Epidemiology• Clinical presentation• Differential• Imaging• Laboratory• Treatment• Reasons for surgery

DiverticulitisDefinition

• 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, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

DiverticulitisDefinition

• Diverticulitis – Fecalith becomes impacted in a diverticulum

– Erosion through the serosa • Perforation


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DiverticulitisPathophysiology

• 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


– 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, 8 th edition, 1999


• 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 – 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


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DiverticulitisEpidemiology

• 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


DiverticulitisEpidemiology

• 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


DiverticulitisClinical 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.


DiverticulitisClinical Manifestations

• Fistulas occur in 5% of patients w/ complicated diverticulitis– Colovesical– Colovaginal– Coloenteric


DiverticulitisDifferential Diagnosis

• Lower abdominal pain, fever, and bloody diarrhea – Bacterial colitis (Shigella,

Salmonella, Campylobacter)– Ischemic colitis– Inflammatory bowel disease

• Generalized peritonitis– Acute abdomen

• Gynecologic disorders – May be localized to the left

lower quadrant (LLQ)

Acute severe abdominal pain – Perforation of an abdominal viscus

• Peptic ulcer• Small bowel obstruction• Choledocholithiasis • Nephrolithiasis• Rupture and dissection of an abdominal aortic

aneurysm – Subacute onset of pain

• Intestinal ischemia • Cholecystitis• Pancreatitis • Diverticulitis• Crohn's disease • Appendicitis

– Pain of a constant nature• Cholecystitis• Pancreatitis• Intestinal ischemia• Inflammatory disorders

– Colicky pain occurs • Nephrolithiasis • Intestinal obstruction

– Radiation of pain • Pancreatitis• Peptic ulcer disease• Biliary tract disease

– Shoulder pain • Diaphragmatic irritation

– Significant vomiting is seen with pancreatitis or obstruction of the stomach or small bowel.

DiverticulitisLaboratory

• Leukocytosis – Common, nonspecific

• Urinalysis – Protein or rare white blood cells may be found

• Nonspecific

• Fecal leukocytes • Should be sought if diarrhea is present


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DiverticulitisImaging

• Abdominal radiographs – May indicate

• A displaced colon• Extraluminal gas• Colonic mucosal abnormalities

– More helpful in excluding other potential causes of left lower quadrant pain.



• 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.



• Computed tomographic scan – Marked thickening of

• Distal end of the descending colon

– Inflammatory changes (straight arrow)

– Extraluminal gas (curved arrow)



• Barium Enema– Colon with sinus

formation – Shows multiple

diverticula– Communicating sinus

is clearly seen (arrow).



• 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



• 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

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DiverticulitisTreatment

• 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.



• 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



• Colon carcinoma may mimic diverticulitis– Colonoscopy or sigmoidoscopy is

recommended 4-6 weeks after recovery when surgery is not performed



• 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



• 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



• Hinchey staging– Stage I

• Colonic inflammation• Pericolic abcess

– Stage II• Colonic inflammation• Retroperitoneal or• Pelvic abcess

– Stage III• Purulent peritonitis

– Stage IV• Fecal peritonitis

• Percutaneous drainage?

• If not….– Sigmoid colectomy w/

primary anastamosis• Stage I or II

– Sigmoid colectomy w/ hartman pouch

• Larger abcesses


Festivals

DiverticulitisReasons for Elective Surgery • CONDITION1. 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

6. Sudden abdominal pain in people taking corticosteroids

• REASON1. 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


Any questions?

diverticulitis robert zaid pgy-1 october 24, 2005 genesys regional medical center

Documents

online version

population older

cecils textbook of medicine

elsevier imprint

schwartz principles

weakest areas

colonic walladjacent

areas weak