Diverticular Disease

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Diverticular Disease

• Dr. Matt W. Johnson

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Introduction Overview

• Pathology
• Physiology
• Location
• Complications
• Bleeding
• Obstruction
• Fistula
• Acute Diverticulitis
• Management of Acute Diverticulitis

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Pathology

• Congenital
• Acquired
• association with Western diets high in refined
  carbohydrates and low in dietary fibre1
• Deficiency of vegetable fibre in diet2
• Disordered motility
• Hyperelastosis may lead to structure change
• Collagen abnormalities
• Age
• Diverticular disease occurs in over 25 of the
  population, increasing with age3

1 Ferzoco et al Lancet 1998 2 Simpson et al Br J
Surg 2002 3 Janes et al BJS 2005
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Physiology

• La Place effects
• High intra-luminal pressure
• Resultant characteristic protrusion mucosa
• Worst at terminal arterial branches
• Rectal sparing
• ?due to complete layer of longitudinal muscle and
  large diameter

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Physiology and Anatomy

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

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Location

• Classically Sigmoid
• In Orient often right-sided
• Rectal Sparing
• Can occur anywhere(but considered
  separately)e.g. Small bowel see later

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Right vs. Left
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Complications

• Obstruction
• Bleeding
• Inflammation itis
• Fistula
• Sepsis
• Perforation
• May co-exist with IBD

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Obstruction in Diverticular Disease

• Progressive distension
• Single contrast enema will delineate this
• Often present like cancer
• Diagnosis
• often only at operation (opened specimen) or
• on histology

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Bleeding in Diverticular Disease

• Rarely exsanguinating
• Often requires repeat transfusion
• Consider mesenteric angiography if available
• Embolisation (risk of ischaemia and infarction)
• Allows targeted resection
• Operative intervention uncommon
• On table colonoscopy
• Exclusion

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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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Fistula

• Abnormal connection
• Commonest communications are
• Colovesical
• Colovaginal (esp if prev TAH)
• Colovesical Symptoms
• Pneumaturia
• Recurrent infections
• Faecalent urine or particulates
• Diagnosis of site/communication vs pathology
• CD/CRC/TCC

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Acute Diverticulitis

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

1 Killingback Surg Clin North Am 1983
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Emergency Presentation

• Symptoms
• Generally unwell
• Pain localising to left iliac fossa
• Abdominal distension
• Altered bowel habit e.g. diarrhoea
• Nausea/Fever
• Signs
• LIF tenderness
• Beware RIF pain-in right sided diverticulitis
  and where sigmoid crosses midline
• Systemic signs (T/HR/BP/WCC)
• May be palpable on pR at anterior rectal wall

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Management

• Resuscitation
• Analgesia
• Bloods
• ECG/Catheter/Urine
• Rectal examination (/-sigmoidoscopy)
• CXR
• AXR
• USS
• CT Scan
• Operative intervention

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CXR
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AXR
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Diverticular disease
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CT Scan
Perforated diverticulitis of the sigmoid colon-CT
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Diverticulitis with pericolic abscess
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Operative Picture
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Perforation
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Operative considerations

• Serial assessment and clinical judgement
• (even if Radiological perforation)
• Operative indications
• generalized peritonitis
• uncontrolled sepsis,
• visceral perforation
• acute clinical deterioration
• At operation
• Resection better than no resection1
• Hartmanns vs anastomosis

1 Krukowski Matheson Br J Surg 1984
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Anastomosis

• Is there any role for primary anastomosis in the
  inflamed bowel?
• Consider if fully resuscitated and colorectal
  Surgeon
• Retrograde gun/washout kit
• Schilling et al. 2001 Diseases of the Colon and
  Rectum
• diverticulitis with peritonitis
• 13 patients one stage
• 42 Hartmanns procedure
• 7 mortality in both groups
• Similar complication rates
• Not a study of bowel obstruction

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Elective Presentation

• Via outpatients
• Often milder version of emergency presentation
• Incidental radiological finding
• AXR
• Contrast study e.g. Barium Enema
• CT scan
• Rarely if insiduous, an abscess may be found on
  Barium Enema as an outpatient

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Elective resection for Diverticultis

• After recovering from an episode of
  diverticulitis the individual risk of an urgent
  Hartmanns is 1 in 2000 patient-years of
  follow-up.
• Surgery for diverticular disease has a high
  complication rate
• 25 of patients have ongoing symptoms after bowel
  resection (IBS/IBD)
• No evidence to support the idea that elective
  surgery should follow two attacks of
  diverticulitis.
• Further prospective trials are required.

1 Janes et al BJS 2005
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Duodenal and Jejunal Diverticulosis

• Separate from colonic diverticulosis.
• Most occur in the jejunum and occasionally
  duodenum.
• Jejunal diverticula are acquired protrusions of
  the mucosal lining through the muscular wall of
  the bowel.
• Encourages particular bacterial overgrowth.
• A combination of alteration of the intraluminal
  contents by these bacteria may result in
  malabsorption
• Calcium
• Iron
• Vitamins D or B12.
• Patients may present with anaemia and
  occasionally 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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• Questions
• ??

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