Diverticular Disease

1. Diverticular Disease Maggie Gordon, R1 September 5, 2006

2. Outline • The disease • Treatment guidelines

3. The Disease

4. Definitions • Colonic diverticulum: herniation of mucosa and muscularis mucosa through colonic wall (technically, a false diverticulum) • Diverticulosis: presence of diverticula without inflammation • Diverticular disease: presence of symptomatic diverticula • Diverticulitis: inflammation and infection associated with diverticula Schwartz's Principles of Surgery - 8th Ed. (2005)

5. Uncomplicated Diverticulitis • Infection, inflammation of diverticulum Presentation: • LLQ pain, tenderness • CT: • pericolic soft-tissue stranding • colonic wall thickening • phlegmon Schwartz's Principles of Surgery - 8th Ed. (2005)

6. Complicated Diverticulitis • Abscess • Obstruction • Diffuse peritonitis (free perforation) • Fistulas, e.g., colovesical, colovaginal, coloenteric, colocutaneous • Haemorrhage Schwartz's Principles of Surgery - 8th Ed. (2005)

7. Complicated Diverticulitis, Abscess Schwartz's Principles of Surgery - 8th Ed. (2005)

8. Epidemiology • very common in Western world • ~50% people > 50 y.o. Schwartz's Principles of Surgery - 8th Ed. (2005)

9. Risk Factors • age • low-fibre diet • obesity • physical inactivity • left-sided colon cancer • Ehlers-Danlos, Marfan’s, polycystic kidney diseases Rabinovitch, “Diverticular disease of the colon”, 2005

10. Etiology  fibre diet  stool volume  intraluminal pressure  colonic wall tension  tensile strength  elasticity  age muscular hypertrophy, pulsion diverticula Schwartz's Principles of Surgery - 8th Ed. (2005), Lawrence Essentials of General Surgery, 2000

11. Pathophysiology Up To Date, 2003

12. Pathophysiology Up To Date, 2003

13. Investigations Townsend: Sabiston Textbook of Surgery, 17th ed., 2004 Schwartz's Principles of Surgery - 8th Ed. (2005)

14. Investigations - CT Air-filled diverticula Mesenteric stranding www.medcyclopaedia.com

15. Investigations - CT Air in bladder Thickened wall www.medcyclopaedia.com

16. Natural History Up To Date, 2003

17. Natural History Up To Date, 2003

18. Natural History Townsend: Sabiston Textbook of Surgery, 17th ed., 2004

19. Treatment Guidelines

20. Uncomplicated Diverticulitis Acute • Bowel rest • iv antibiotics • Merperidine better than morphine 3 weeks later • Scope to rule out cancer 4-6 weeks later • Elective resection, if appropriate… Townsend: Sabiston Textbook of Surgery, 17th ed., 2004

21. SSAT Recommendations Indications for elective operation • ≥ 2 acute attacks, successfully treated medically • one attack requiring hospitalization in patient <40 y.o. • one complicated attack • one attack in immunocompromised patient • inability to rule out colonic carcinoma www.ssat.com/cgi-bin/divert.cgi

22. Complicated Diverticulitis, Abscess Hinchey Stages I (pericolic abscess) and II (retroperitoneal or pelvic abscess) • Pre-op CT-guided percutaneous drainage • Elective resection, primary re-anastomosis Hinchey Stage III (purulent peritonitis) • Emergent Hartmann’s procedure, or • Emergent resection, primary re-anastomosis Hinchey Stage IV (feculent peritonitis) • Emergent Hartmann’s procedure Conyers, “Diverticulitis. To cut or not to cut?”, 2005

23. Complicated Diverticulitis, Fistula • Treat acute attack • Elective resection, primary re-anastomosis Colovesical fistula • Foley x 7-10 days Townsend: Sabiston Textbook of Surgery, 17th ed., 2004

24. Complicated Disease, Haemorrhage • Resuscitation If bleeding persistent, recurrent: • Emergent / elective resection, primary re-anastomosis Schwartz's Principles of Surgery - 8th Ed. (2005)