Document Sample
Western population
• ½ of individuals >60y/o
• 20% of patients develop symptomatic disease

United States
• >200,000 hospitalization annually
• 5th most costly GI disorder
• Mean hospital stay: 9.7 days
• Average cost: $42,000/patient
• Mean age at presentation: 59 years
• F=M, men present at younger age
       Underdeveloped countries
        • Rare, diets include more fiber and rough-age
        • However, shortly following migration in the U.S., immigrants
          will develop diverticular disease at the same rate as U.S.

        • Extrapolated prevalence: 634,130 out of 86,241,697
          (population estimated)*
        • Extrapolated incidence: 95,119 out of 86,241,697
          (population estimated)*
* US Census Bureau, International Data Base, 2004 ( the extrapolations for Diverticular Disease are only estimates and may
have limited relevance to the actual incidence of Diverticular Disease in any region)

            - involves only protrusion of the
            mucosa through the muscularis
            propria of the colon
            - most common

            - a saclike herniation of the entire
            bowel wall
                   Protrusion occurs at the point where the
                  NUTRIENT ARTERY or VASA RECTI penetrates
                        through the muscularis propria

                    Break in the integrity of the colonic wall

                            Compression or erosion

                     PERFORATION                  BLEEDING
               commonly affect the SIGMOID COLON
              due to:

                   Relative high pressure zone within
                   the muscular sigmoid colin.

                   Higher amplitude contractions
                   combined with constipated, high fat
                   content stool within the sigmoid
                   lumen results in the creation of these

               Related to retention of particulate
              material within the diverticular sac and
              formation of fecalith
Presentation, Evaluation, and Management
Diverticular Bleeding
• Hemorrhage from a colonic diverticulum is the most common
  cause of hematochezia in patients >60 years.
• Only 20% of patients with diverticulosis will have GI bleeding.
• Most bleeds are self-limited and stop spontaneously with
  bowel rest.
• Lifetime risk of rebleeding: 25%
Diverticular Bleeding
• Colonoscopy
   To localize the bleeding
   May be both diagnostic and therapeutic in the management of mild to
    moderate diverticular bleeding

• Angiography
   Management of massive bleeding in a stable patient
   Mesenteric angiography can localize the bleeding site and occlude the
    bleeding vessel successfully with a coil in 80% of the cases
   Follow up: Repetitive colonoscopy to look for evidence of colonic

• Segmental resection of the colon
   To eliminate risk of further bleeding
   In patients on chronic blood thinners
Diverticular Bleeding
• Highly selective coil embolization
   Rate of colonic ischemia: <10%
   Risk of acute rebleeding: <25%

• Selective infusion of vasopressin
   To stop hemorrhage
   Complications: MI, intestinal ischemia
   Recurrence of bleeding in 50% of patients once infusion is
Diverticular Bleeding
• Surgery
   Indications: if patient is unstable or has had a 6-unit
    bleed within 24 h
   Total abdominal colectomy
     Patients with presumed bleeding from diverticular
      disease requiring emergent surgery without localization
     Rationale: Colonic diverticulosis is more often seen from
      the R colon
   Surgical resection with primary anastomosis
     In patients without severe comorbidities
Presentation, Evaluation, and Management
Uncomplicated – 75%    Complicated – 25%
Abdominal Pain         Abscess 16%
Fever                  Perforation 10%
Leukocytosis           Stricture 5%
Anorexia/obstipation   Fistula 2%
• Diverticular perforation
   Generalized peritonitis in <25% of cases
   (+) Abdominal distention

• Giant diverticulum of the sigmoid
   (+) Air fluid level in the LLQ on plain abdominal film
   Mx: resection to avoid impending perforation
• Diagnosis is best made on CT.
• Suspected diverticulitis that does not meet CT
  criteria or is not associated with a leukocytosis or
  fever is not diverticular disease
• Conditions that mimic diverticular disease:
   IBS
   Ovarian cyst
   Endometriosis
   Acute appendicitis
   PID
• Barium enema or colonoscopy
  Should be performed ~6 weeks after an attack of
   diverticular disease
    A sigmoid malignancy can masquerade as diverticular
  Should not be performed in the acute setting
    Higher risk of colonic perforation associated with
     insufflation or insertion of barium-based contrast
     material under pressure.
• Complicated diverticular disease
   Diverticular disease associated with an abscess or
    perforation, and less commonly with a fistula.
   With fistula formation
     Common locations include cutaneous, vaginal or vesicle
     Present with either passage of stool through skin or
      vagina, or pneumaturia
     Colovaginal fistulae: more common in women who have
      undergone hysterectomy
Hinchey Classification of Perforated Diverticular
Medical Management of
Diverticular Disease
• Asymptomatic
  Diet alterations – fiber-enriched diet, including 30g of
  Supplementary fiber products: Metamucil, Fibercon,
  Avoid nuts and popcorn – may obstruct the lumen of
   the diverticulum
Medical Management of
Diverticular Disease
• Symptomatic
   Radiographic and hematologic confirmation of inflammation and
    infection within the colon

   Treated initially with antibiotics and bowel rest
       TMP-SMX or ciprofloxacin and metronidazole
       (+) Ampicillin – for nonresponders
       Alternative: IV piperacillin or oral penicillin/clavulinic acid
       Usual course: 7-10 days
       Rifixamin + fiber – less frequent recurrent symptoms from
        uncomplicated diverticular disease

   Limited diet until pain resolves
   Medical therapy can be continued beyond 2 attacks without an
    increased risk of perforation requiring a colostomy, especially in
    those >50 years.
Surgical Management of
Diverticular Disease
• In patients who are low risk (ASA I and II) who have
  had at least 2 documented attacks requiring
  hospitalization or those who do not rapidly improve
  on medical therapy
• Younger patients – more aggressive form of disease
  ▫ Waiting beyond two attacks is not recommended.
• In all low surgical risk patients with complicated
  diverticular disease
Surgical Management of
Diverticular Disease
• Goals of Surgical Management
  Control sepsis
  Eliminate complications such as fistula or obstruction
  Remove diseased colonic segment
  Restore intestinal continuity
Surgical Management of
Diverticular Disease
Surgical Management of
Diverticular Disease
 • Open or laparoscopic sigmoid resection – current option
   of uncomplicated diverticular disease

 • Benefits of laparoscopic over open resection:
   ▫ Early discharge (by at least 1 day)
   ▫ Less narcotic use
   ▫ Earlier return to work

 • Benefits of open over laparoscopic resection:
   ▫ Shorter operative procedure
   ▫ Less costly

 • Complication rates are similar.
Surgical Management of
Complicated Diverticular Disease
                        Proximal diversion of the fecal
                         stream with an ileostomy or
                         colostomy and sutured omental
                         patch with drainage
                        Resection with colostomy and
                         mucus fistula or closure of distal
                         bowel with formation of a
                         Hartmann’s pouch
                        Resection with anastomosis
                        Resection with anastomosis and
                         diversion (coloproctostomy with
                         loop ileostomy or colostomy)
Surgical Management of
Diverticular Diseases
• Hinchey Stages I and II
  ▫ Percutaneous drainage followed by resection with
    anastomosis about 6 weeks later
  ▫ Percutaneous drainage
     For abscesses ≥ 5 cm with a well-defined wall that is
     If <5cm, may resolve with antibiotics alone
     Contraindications to percutaneous drainage:
       No percutaneous access route
       Pneumoperitoneum
       Fecal peritonitis
Surgical Management of
Diverticular Diseases
• Hinchey Stages I and II
  ▫ If patients develop generalized peritonitis 
    Hartmann’s procedure
  ▫ Nonoperative therapy – 20% recurrence rate at 2 years
    in patients with Hinchey Stage I disease
  ▫ 80% of patients with Hinchey Stage II required surgical
    resection for recurrent symptoms.
Surgical Management of
Diverticular Diseases
• Hinchey Stage III
  ▫ Hartman’s procedure or with primary anastomosis and
    proximal diversion
  ▫ If patient has significant comorbidities: intraoperative
    peritoneal lavage (irrigation), omental patch to the
    oversewn perforation, and proximal diversion of the fecal
    stream with either an ileostomy or transverse colostomy
    can be performed

• Hinchey Stage IV
  ▫ No anastomosis of any type should be attempted.
Recurrent Symptoms in
Diverticular Disease
• Occurs in 10% of patients.
• Recurrence develops in patients following
  inadequate surgical resection.
• A retained segment of diseased rectosigmoid colon is
  associated with twice the incidence of recurrence.
• IBS – may also cause recurrence of initial symptoms
• Patients undergoing surgical resection for presumed
  diverticulitis and symptoms consistent with IBS have
  functionally poorer outcomes.

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