Colonic Diverticulosis: A review

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Colonic Diverticulosis A review

• Dr. Matt W. Johnson BSc MBBS MRCP MD
• Consultant Gastroenterologist

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Diverticulosis
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Operative Picture
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Introduction

• Diverticular ? disease (or Variant of
  normal ?)
• Prevalence 40 in those gt50y
• 70 of those gt80y
• 68,000 Hospital admissions / year in UK
• 2,000 deaths / year in UK
• Spiller RC. Mechanistic RCT of Mesalazine in
  Symptomatic Diverticular Disease. Clinical Trial
  number NCT00663247. 2010
• Diverticular disease and diverticulitis, Clinical
  Knowledge Summaries (March 2008)

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Diverticulosis Demand on LDServices

• 70-80 of new patient clinic appointments are for
  ABHs
• Over the last 7y 12,000 FSs
• Of these-
• 5,500 Normal 47
• 500 Haemorrhoids lt5
• 2,000 Diverticulosis 17
• 580 Colitis 5
• 500 Rectal Cancer and Polyps lt5

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Introduction

• BSG recommendation re - terminology
• Diverticulosis - Asymptomatic (75)
• Diverticular disease - Symptomatic (lt25)
• Diverticulitis - Inflamed/Infected (75)
• Diverticular colitis - Associated colitis
• Diverticular bleeding - 15

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Introduction Overview

• Epidemiology
• Pathophysiology
• Diverticulosis
• Complications
• Symptomatic DD
• Diverticulitis
• Diverticular colitis
• Diverticular haemorrhage
• Stricture obstruction
• Fistula
• Management

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Cross Sectional Bowel Anatomy
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Cross Section of Diverticulae
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Physiology and Anatomy

• Terminal arterial branches
• Penetrate circular muscle
• Often lie adjacent to taenia

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Physiology

• High intra-luminal pressure gradient
• Weakest at the point where the terminal arterial
  branches penetrate through the circular muscles.
• Rectal sparing
• ?due to complete layer of longitudinal muscle and
  large diameter

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Pathology

• Congenital
• Acquired - Multifactorial
• Mychosis
• Increased depositioning of collagen elastin in
  taeniae shortening and thickening narrowing
  with increased luminal pressures
• Hypersegmentation
• Non-propulsive contraction of circular muscle in
  closed segment increases luminal pressure
  herniation
• Laplaces Law
• Transmural P gradient Wall tension radius
  Sigmoid
• Structural wall abnormalities
• Ehlers Danlos, Marfans, PCKD - Reduced tensile
  strength of CT
• Dietary factors 123
• West (insoluble fibre) gt East (soluble fibre)
  rare in Africa
• Insoluble stool fibre increases stool bulk
  larger colon diameter impaired segmental
  contractions higher intra-luminal pressures

1 Ferzoco et al Lancet 1998 2 Simpson et al Br J
Surg 2002 3 Janes et al BJS 2005
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Idiopathic Slow Transit Constipation
Day 5 after taking markers
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Diverticulosis

• 75 most found incidentally
• When questioned most will have symptoms ie
  Diverticular disease
• No proven evidence that Mx helps prevent
  enlargement or further development of diverticulae

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Epidemiology - Location

• Classically Sigmoid
• In Orient often right-sided
• Rectal Sparing
• Can occur anywheree.g. Small bowel

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Diverticulosis
Right Sided
Left Sided
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Diverticular Disease

• Altered bowel habits (pellets / loose)
• Bloating / Flatulence / Borborygmi
• Incomplete evacuation
• LIF discomfort relieved by defaecation
• Mx Soften and shift stool
• High fluid gt2L/d
• Low residue (high soluble fibre) diet
• /- Movicol 1 sachet bd
• /- Mesalazines
• /- Buscopan / Spasmolol / Colperamin /
  Mebeverine
• Avoid opioids Loperamide

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Diverticulitis

• Cause
• Inspissation of faecal content stuck in
  diverticlum
• Obstruction of the diverticulum
• Increased pressure local ischaemia breakdown
  of mucosal barrier
• Localise bacterial overgrowth translocation
  across membrane micro-abscesses

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SSs of Diverticulitis

• Symptoms
• LIF pain (can be right sided)
• ABH / Diarrhoea
• NV
• Signs
• Pyrexia (Temp gt 38C)
• Wbc (gt12)
• ESR or CRP
• CXR AXR
• US lt CT scan (exclude complications eg. abscess)

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Management

• Ix
• Bloods
• Rectal examination (avoid sigmoidoscopy for 2
  weeks)
• CXR
• AXR
• USS or CT Scan
• Mx
• Resuscitation IV fluids
• Antibiotics
• Analgesia
• Operative intervention

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Hinchney Classification of Diverticulitis
Grade Extent Mortality Prognosis
1 Localised abscess lt5
2 Abscess into pelvis 5
3 Purulent peritonitis 13
4 Faeculant peritonitis 43
Hinchney EJ. AdvSurg.19781285-109
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Acute Diverticulitis

• Abscess
• Peridiverticular
• Mesenteric
• Pericolic
• Perforation
• Concealed
• Free
• Peritonitis (gangrenous sigmoidits)
• Purulent or serous or faecal
• Local or generalised or pelvic

1 Killingback Surg Clin North Am 1983
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Diverticulitis with pericolic abscess
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Management of Complicated Diverticulitis

• Mild / Grade 1
• Mx Outpatient, High fluid low residue diet
• Rx OP ABs 7-10d
• (Metronidazole Co-amoxiclav or Ciprofloxacin)
• Moderate / Grade 2
• Mx In-patient, As above
• Rx IV Abs /- XR guided drainage
• Severe / Grade 34 or with Complications
• Mx IP Resuscitation, As above
• Rx IV ABs Contact Surgeons

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Elective resection for Diverticulitis

• Emergency surgery for perforated Diverticulosis
  with peritonitis Mortality rate of 7 1
• Diverticular Surgery High complication rate 2
• For emergency surgery Primary anastomosis
• A RMCCT found one-stage procedure (primary
  anastomosis) significantly reduced rates of
  postoperative peritonitis and emergency
  re-operation compared with a two-stage procedure
  (formation of an end colostomy with oversewing of
  the rectal stump - Hartmann's procedure) 3
• 25 of patients have ongoing symptoms after bowel
  resection (IBS/IBD) 3
• No evidence to support elective prophylactic
  surgery

1 Schilling et al. 2001 Diseases of the Colon and
Rectum 2 Krukowski Matheson Br J Surg 1984 3
Janes SE, Meagher A, Frizelle FA Management of
diverticulitis. BMJ. 2006 Feb 4332(7536)271-5
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Diverticular colitis

• Presentations
• Asymptomatic
• Bloody diarrhoea
• Abdo pain
• Affects sigmoid like UC but doesnt effect rectum
• Rx Mesalazines 1,2,3,4

1 Spiller RC. NCI00663247 2 Mario F. JClinGastro.
200640Suppl3S1. 55-9 3 G. Did Dis Sci.
2007522934-41 4 A. Dig Dis Sci. 2007.
200752671-4
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Complications of Diverticulitis

• Bleeding1 (15-25)
• Perforation (25)
• Obstruction
• Fistulae
• Abscess
• May co-exist with IBD

1 Travis S. Colonic Diverticular Disease 2005312
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Bleeding in Diverticular Disease

• 3-5 of all diverticulosis
• 15-25 of all the diverticulitis 1
• Accounts for 40 of all LGI bleeding 1
• 75-90 stop spontaneously 2
• 10-40 risk of re-bleed 2
• Morbidity Mortality rate 10-20 3

1 Gostout CJ. JClinGastro. 199214(3)260 2
McGuire HH Jr. Ann Surg. 1994220(5)653 3 Uden
P. Dis Colon Rectum. 198629(9)561
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Management of Diverticular Bleeds

• Mx
• Resuscitation Transfusion
• Rbc labelling scan (0.1ml/m)
• Localisation 24-91
• Mesenteric angiography (0.5ml/m)
• /- Embolism
• Endoscopic therapies
• Adrenaline /- Endoclips
• Sx targeted resection

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Re-Bleeding Rates

• Re-bleeding rate

Year Percentage
1 9
2 10
3 19
4 25
1 Longstreth Am J Gastro 1997
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Other Causes Of Colonic Bleeding

• Exclude
• IBD
• Neoplasm
• Angiodysplasia
• Ischaemic colitis
• Radiation proctitis
• Varices

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Perforation (35 Mortality)
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CT Scan
Perforated diverticulitis of the sigmoid colon-CT
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CXR
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AXR
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Obstruction in Diverticular Disease

• Increased fibrotic reaction leads to stricturing
• Often present like cancer
• Progressive distension with faecal loading
• Single contrast enema will delineate this
• Diagnosis
• often only at operation (opened specimen) or
• on histology

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Fistula

• Abnormal connections
• Colovaginal (esp if prev TAH)
• Colovesical
• Pneumaturia
• Recurrent infections
• Faecalent urine or particulates

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Duodenal and Jejunal Diverticulosis

• Different to colonic diverticulosis.
• Most occur in jejunum and (occasionally)
  duodenum.
• Commonly associated with bacterial overgrowth.
• Jejunal diverticula are acquired secondary to
  protrusions of the mucosal lining through the
  muscular wall of the bowel.
• Vitamin deficiencies
• Increased colonic transit Reduced Vit D (Ca)
  Iron
• SBBO Reduced B12 Increased Folate
• Patients may present with anaemia and
  osteomalacia.

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Proximal Jejunal Diverticulitis
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Incidental Jejunal Diverticular
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Proximal Jejunal diverticulitis with perforation
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Further Reading

• COLONIC DIVERTICULOSIS A REVIEW
• Tyara Banerjee,
• Suman Verma,
• Matthew W. Johnson.
• Good Clinical Care

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Graham Hollands Lutonthe optimism and the
frustration of living in a metropolis