Conservative management versus early surgical resection in right-sided diverticulitis

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2. Case presentation. HPI: EM is a 53 yo F w/ PMH significant for cecal diverticulitis Dx'd in 2003 (see below) p/w 4 day hx of RLQ pain, nausea, fevers/chills, diarrhea. No vomiting. Started on cipro/flagyl PO as outpt 2 days prior to admission. Seen as outpt 1 day prior to admission. Last c-scope 2007..

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Conservative management versus early surgical resection in right-sided diverticulitis

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1. Conservative management versus early surgical resection in right-sided diverticulitis Steven B. Porter, MD PGY-1, Department of Surgery Team IV Rounds May 2, 2008

2. 2 Case presentation HPI: EM is a 53 yo F w/ PMH significant for cecal diverticulitis Dx’d in 2003 (see below) p/w 4 day hx of RLQ pain, nausea, fevers/chills, diarrhea. No vomiting. Started on cipro/flagyl PO as outpt 2 days prior to admission. Seen as outpt 1 day prior to admission. Last c-scope 2007.

3. 3 Case Presentation cont’d PMH: cecal diverticulitis, asthma, anxiety Meds: montelukast, sertraline, psyllium PSH: lap appendectomy/R oophorectomy 2003, lap L oophorectomy 2000 for cyst All: NKDA FHx: no diverticulitis, no colon ca SHx: no tobacco in >20 yrs, social etoh, no drugs

4. 4 Case Presentation cont’d PE VS: T 37.1, HR 90, BP 113/65, RR 20 Gen: NAD, speaking in full sentences CV: RRR, no murmurs Pulm: CTA b/l, no wheezes Abd: soft, +BS, TTP in RLQ, no rebound or guarding Extr: 2+ DP pulses b/l, no cyanosis, no rash Rectal: heme neg stool Labs: WBC 11.3, Hct 33.9, Plts 290, BMP WNL, INR 1.2

5. 5 Case Presentation cont’d

6. 6 Case Presentation cont’d Hospital Course IVF, NPO, IV antibiotics (Zosyn) Advanced to clears, pain subsided WBC decreased 11.3?7.9?5.8 Advanced to GIS D/c’d to home on Hospital Day #5 with PO antibiotics

7. 7 Background What are colonic diverticula? ?Sabiston: true diverticulum false diverticulum or pseudodiverticulum

8. 8 Normal Cecum

9. 9 Diverticula

10. 10 Pathophysiology

11. 11 Diverticulitis

12. 12 Uncomplicated Diverticulitis

13. 13 Complicated Diverticulitis

14. 14 Classification of Diverticulitis Hinchey Stage(11) Stage I: Pericolic or mesenteric abscess Stage II: Walled-off pelvic abscess Stage III: Generalized purulent peritonitis Stage IV: Generalized fecal peritonitis

15. 15 Theories on RS Theories on RS in the East tend to mirror those of LS in the West: an increase in incidence of RS in Far East(4) this has correlated with a decrease in fiber intake(5), especially in urban centers(6) false diverticula just as in LS in the West(8)

16. 16 Epidemiology of RS RS disease is quite common in the Far East. Estimates of >70% of diverticular disease in Japan, Korea, China, Singapore, Taiwan, and Thailand(1). Other estimates put it as high as 80%(9). Incidence quotes for RS diverticulitis range from 1:34(10) to 1:300(7) appendectomies.

17. 17 Conservative Management

18. 18 Conservative Management

19. 19 Conservative Management

20. 20 Conservative Management

21. 21 Conservative Management

22. 22 Conservative Management

23. 23 Conservative Management

24. 24 Conservative Management

25. 25 Conservative Management

26. 26 Conservative Management

27. 27 Conservative Management

28. 28 Conservative Management

29. 29 Conservative Management

30. 30 Conservative Management

31. 31 Early Surgical Resection

32. 32 Early Surgical Resection

33. 33 Early Surgical Resection

34. 34 Early Surgical Resection

35. 35 Early Surgical Resection

36. 36 For Comparison with LS

37. 37 Conclusions and Attendings’ Comments

38. 38 References 1. Nakaji S, Danjo K, Munakata A, et al. Comparison of etiology of right-sided diverticula in Japan with that of left-sided diverticula in the West. Int J Colorectal Dis 2002;17:365-73. 2. Morson BC. The Muscle Abnormality In Diverticular Disease Of The Colon. Proc R Soc Med 1963;56:798-800. 3. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969;10:336-44. 4. Nakada I, Ubukata H, Goto Y, et al. Diverticular disease of the colon at a regional general hospital in Japan. Dis Colon Rectum 1995;38:755-9. 5. Munakata A, Iwane S, Ohta M, Nakaji S, Sugaware K, Mori B. Time trends of dietary fiber intake in Japan. J Epidemiol 1995:89-94. 6. Inoue M. The epidemiologic and clinical features of diverticular disease of the colon (in Japanese). J Jpn Soc Coloproctol 1992:904-913. 7. Sugihara K, Muto T, Morioka Y. Motility study in right sided diverticular disease of the colon. Gut 1983;24:1130-4. 8. Murayama N, Baba S, Kodaira S, Abe O. An aetiological study of diverticulosis of the right colon. Aust N Z J Surg 1981;51:420-5. 9. Sugihara K, Muto T, Morioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984;27:531-7. 10. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings--new insights about frequency and natural history. Radiology 1998;208:611-8.

39. 39 References cont’d. 11. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85-109. 12. Yang HR, Huang HH, Wang YC, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929-34. 13. Komuta K, Yamanaka S, Okada K, et al. Toward therapeutic guidelines for patients with acute right colonic diverticulitis. Am J Surg 2004;187:233-7. 14. Ngoi SS, Chia J, Goh MY, Sim E, Rauff A. Surgical management of right colon diverticulitis. Dis Colon Rectum 1992;35:799-802. 15. Poon RT, Chu KW. Inflammatory cecal masses in patients presenting with appendicitis. World J Surg 1999;23:713-6; discussion 716. 16. Chiu PW, Lam CY, Chow TL, Kwok SP. Conservative approach is feasible in the management of acute diverticulitis of the right colon. ANZ J Surg 2001;71:634-6. 17. Leung WW, Lee JF, Liu SY, et al. Critical appraisal on the role and outcome of emergency colectomy for uncomplicated right-sided colonic diverticulitis. World J Surg 2007;31:383-7. 18. Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE, Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629-34; discussion 634-5. 19. Harada RN, Whelan TJ, Jr. Surgical management of cecal diverticulitis. Am J Surg 1993;166:666-9; discussion 669-71. 20. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the American experience. Dis Colon Rectum 1987;30:821-6. 21. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185:135-40.

40. 40 References cont’d. 22. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171:244-6. 23. Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg 1994;179:156-60. 24. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994;76:117-20. 25. Haglund U, Hellberg R, Johnsen C, Hulten L. Complicated diverticular disease of the sigmoid colon. An analysis of short and long term outcome in 392 patients. Ann Chir Gynaecol 1979;68:41-6. 26. Larson DM, Masters SS, Spiro HM. Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976;71:734-7. 27. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969;4:639-42. 28. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4:53-69.

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