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Diverticular Disease. Maggie Gordon, R1 September 5, 2006. Outline. The disease Treatment guidelines. The Disease. Definitions. Colonic diverticulum: herniation of mucosa and muscularis mucosa through colonic wall (technically, a false diverticulum)

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diverticular disease

Diverticular Disease

Maggie Gordon, R1

September 5, 2006

outline
Outline
  • The disease
  • Treatment guidelines
definitions
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)

uncomplicated diverticulitis
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)

complicated diverticulitis
Complicated Diverticulitis
  • Abscess
  • Obstruction
  • Diffuse peritonitis (free perforation)
  • Fistulas, e.g., colovesical, colovaginal, coloenteric, colocutaneous
  • Haemorrhage

Schwartz's Principles of Surgery - 8th Ed. (2005)

complicated diverticulitis abscess
Complicated Diverticulitis, Abscess

Schwartz's Principles of Surgery - 8th Ed. (2005)

epidemiology
Epidemiology
  • very common in Western world
  • ~50% people > 50 y.o.

Schwartz's Principles of Surgery - 8th Ed. (2005)

risk factors
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

etiology
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

pathophysiology
Pathophysiology

Up To Date, 2003

pathophysiology12
Pathophysiology

Up To Date, 2003

investigations
Investigations

Townsend: Sabiston Textbook of Surgery,

17th ed., 2004

Schwartz's Principles of Surgery - 8th Ed. (2005)

investigations ct
Investigations - CT

Air-filled diverticula

Mesenteric stranding

www.medcyclopaedia.com

investigations ct15
Investigations - CT

Air in bladder

Thickened wall

www.medcyclopaedia.com

natural history
Natural History

Up To Date, 2003

natural history17
Natural History

Up To Date, 2003

natural history18
Natural History

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

uncomplicated diverticulitis20
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

ssat recommendations
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

complicated diverticulitis abscess22
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

complicated diverticulitis fistula
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

complicated disease haemorrhage
Complicated Disease, Haemorrhage
  • Resuscitation

If bleeding persistent, recurrent:

  • Emergent / elective resection, primary re-anastomosis

Schwartz's Principles of Surgery - 8th Ed. (2005)