Diverticulitis

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Diverticulitis

• Robert Zaid PGY-1
• October 24, 2005
• Genesys Regional Medical Center

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Barcelona - Gaudi
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DiverticulitisOutline

• Definition
• Pathophysiology
• Epidemiology
• Clinical presentation
• Differential
• Imaging
• Laboratory
• Treatment
• Reasons for surgery

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DiverticulitisDefinition

• Diverticula

• Etiology
• Outpouchings
• Occur in areas weak and under stress
• Prolapse of mucosa and submucosa may occur.
• Location
• Arteries penetrate the muscularis to reach the
  submucosa and mucosa.
• Diverticula form through entire colon
• Left colon
• Sigmoid (most common)
• Right sided (uncommon)

http//health-pictures.com/diverticulitis-picture.
htm
Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
5
DiverticulitisDefinition

• Diverticulitis

• Fecalith becomes impacted in a diverticulum
• Erosion through the serosa
• Perforation

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
6
Citadel Park
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DiverticulitisPathophysiology

• Diverticula
• Acquired or congenital
• Can affect small or large intestine
• May be related to an increase in intramural
  pressure
• Occurs in the weakest areas of the colonic wall
• Adjacent to the vasa recta
• Mesenteric side of the colon

Joffe, S, Kachulis, A., Emedicine, Online
Version, 2005, Colon, diverticulitis,
www.emedicine.com
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DiverticulitisPathophysiology

• Theories
• Deficiency in dietary fiber
• Western diet
• Decreased fecal bulk
• Narrowing of the colon
• Small fecal mass
• Increased intraluminal pressure needed to move
  material
• Loss of tensile strength
• Decrease in elasticity
• Proof?
• High fiber diet appears to decrease incidence

Brunicardi, C., F., Schwartz principles of
surgery, pp 1082-1084, 8th edition, 1999
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DiverticulitisPathophysiology

• Diverticula
• False diverticula (pulsion)
• Herniation through colonic wall
• Mucosa
• Muscularis
• Occur between tenia coli
• Points of weakness
• High intraluminal pressure
• Bleeding is self limiting
• True diverticula
• Rare and usuall congenital
• Comprise all layers of bowel wall

Brunicardi, C., F., Schwartz principles of
surgery, pp 1082-1084, 8th edition, 1999
10
DiverticulitisPathophysiology

• Diverticulitis
• Inflammation in and around a diverticulum
• Stagnation of nonsterile inspissated fecal
  material (fecalith)
• May compromise the blood supply
• Cusing inflammatory erosion of the mucosal lining
  
• Perforation
• Intramural abscess
• Fibrinous exudate
• Abscess formation
• Local adhesions
• Peritonitis
• Sealed-off abscesses
• Contained sinus tracts
• Fistulas

Joffe, S, Kachulis, A., Emedicine, Online
Version, 2005, Colon, diverticulitis,
www.emedicine.com
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La Familia
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DiverticulitisEpidemiology

• Frequency in US
• Diverticular disease
• 5 of population at age 40
• 33-50 of population older than 50
• 80 of population older than 80
• Diverticulitis
• 10-20 of patients with diverticular disease
• Frequency internationaly
• Diverticulosis occurs in 0.2 of population

Joffe, S, Kachulis, A., Emedicine, Online
Version, 2005, Colon, diverticulitis,
www.emedicine.com
13
DiverticulitisEpidemiology

• Mortality and Morbidity
• 20 require surgical therapy
• Mortality rate of 7.7 (if peritonitis is
  present)
• Race
• Asians predisposed to right sided diverticulitis
• Sex
• No relationship
• Age
• Disease increases with age

Joffe, S, Kachulis, A., Emedicine, Online
Version, 2005, Colon, diverticulitis,
www.emedicine.com
14
DiverticulitisClinical Manifestations

• Symptoms
• Pain
• Typically located in left lower quadrant
• Subacute and constant pain
• Right sided diverticulitis can occur
  (congenital?)
• Fever
• Almost invariably present
• High-grade fever and sepsis
• If perforation is not contained or
• When the peritonitis is generalized
• Constipation or loose stools may be reported
• Rectal bleeding is unusual.

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
15
DiverticulitisClinical Manifestations

• Fistulas occur in 5 of patients w/ complicated
  diverticulitis
• Colovesical
• Colovaginal
• Coloenteric

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
16
DiverticulitisDifferential Diagnosis

• Lower abdominal pain, fever, and bloody diarrhea
• Bacterial colitis (Shigella, Salmonella,
  Campylobacter)
• Ischemic colitis
• Inflammatory bowel disease
• Generalized peritonitis
• Acute abdomen
• Gynecologic disorders
• May be localized to the left lower quadrant (LLQ)

• Acute severe abdominal pain
• Perforation of an abdominal viscus
• Peptic ulcer
• Small bowel obstruction
• Choledocholithiasis
• Nephrolithiasis
• Rupture and dissection of an abdominal aortic
  aneurysm
• Subacute onset of pain
• Intestinal ischemia
• Cholecystitis
• Pancreatitis
• Diverticulitis
• Crohn's disease
• Appendicitis
• Pain of a constant nature
• Cholecystitis
• Pancreatitis
• Intestinal ischemia
• Inflammatory disorders

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DiverticulitisLaboratory

• Leukocytosis
• Common, nonspecific
• Urinalysis
• Protein or rare white blood cells may be found
• Nonspecific
• Fecal leukocytes
• Should be sought if diarrhea is present

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
18
Candy Factory
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DiverticulitisImaging

• Abdominal radiographs
• May indicate
• A displaced colon
• Extraluminal gas
• Colonic mucosal abnormalities
• More helpful in excluding other potential causes
  of left lower quadrant pain.

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
20
DiverticulitisImaging

• Abdominal CT
• Test of choice
• May demonstrate
• Bowel wall thickening
• Abscess formation
• Diverticula
• Diagnostic barium enema
• Safe when carefully performed
• Findings include
• Spiculation of the mucosa
• Spasm
• Frank perforation
• Abscess
• Findings specific for diverticulitis, but may be
  hard to distinguish from carcinoma
• CT and barium enema are complementary
• Neither is 100 sensitive or specific.

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
21
DiverticulitisImaging

• Computed tomographic scan
• Marked thickening of
• Distal end of the descending colon
• Inflammatory changes (straight arrow)
• Extraluminal gas (curved arrow)

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
22
DiverticulitisImaging

• Barium Enema
• Colon with sinus formation
• Shows multiple diverticula
• Communicating sinus is clearly seen (arrow).

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
23
DiverticulitisImaging

• Endoscopic examination
• Contraindicated with diverticulitis
• Theoretical potential to exacerbate perforation
• Can detect diverticulosis before or between
  attacks
• Sigmoidoscopy
• Appropriate when
• Carcinoma or
• Inflammatory bowel disease is highly suspected

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
24
DiverticulitisImaging

• Colonoscope
• Wide-mouthed openings to diverticula
• Colonoscopy may be difficult and hazardous when
  diverticula are large enough to admit the tip of
  the scope.

Beers, M., 2005, Merck Manual of Medical
Information, Online version, http//www.merck.com/
mmhe/sec09/ch128/ch128c.html
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Street entertainers
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DiverticulitisTreatment

• Mild diverticulitis
• Initially (symptoms usually disappear rapidly)
• Rest
• A liquid diet
• Oral antibiotics
• After a few days
• Soft, low-fiber diet and take a daily psyllium
  (i.e. metamucil) seed preparation.
• After 1 month
• A high-fiber diet can be started
• Severe symptoms (perforation, peritonitis)
• Admitted to hospital
• Intravenous fluids and antibiotics
• Bedrest
• Nothing by mouth until the symptoms subside
• About 20 of people who have diverticulitis
  require surgery because the condition does not
  improve.

Beers, M., 2005, Merck Manual of Medical
Information, Online version, http//www.merck.com/
mmhe/sec09/ch128/ch128c.html
27
DiverticulitisTreatment

• Inpatient
• Broad-spectrum antibiotics
• Third-generation cephalosporin
• Ceftriaxone 1.5mg intravenously daily
• Anaerobic coverage
• Metronidazole 250mg intravenously three times
  daily
• At discharge
• Oral antibiotics to complete 14 day course
• Ciprofloxacin and Metronidazole)
• Outpatient (mild disease)
• Oral antibiotics (14 days)
• Ciprofloxacin (500mg twice daily)
• Metronidazole (250mg three times daily) for 14
  days
• Bowel rest

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
28
DiverticulitisTreatment

• Colon carcinoma may mimic diverticulitis
• Colonoscopy or sigmoidoscopy is recommended 4-6
  weeks after recovery when surgery is not performed

Brunicardi, C., F., Schwartz principles of
surgery, pp 1082-1084, 8th edition, 1999
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DiverticulitisTreatment

• Early surgical consultation is important
• Especially in the presence of significant pain or
  
• An acute abdomen
• Percutaneous catheter drainage
• If large abcess is present
• Temporary

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
30
DiverticulitisTreatment

• Some reasons for surgery
• Colonic stricture
• Bleeding
• Fistula formation to
• The small bowel
• Colon
• Bladder
• Vagina
• Surgcial resection
• Warranted in reoccurrences (1/3 of all patients)
• Sigmoid colectomy with anastamosis

Saunders, W., B., Wilcox, M., 2004, Elsevier
imprint, Cecils Textbook of Medicine, Chapter
143, Online version, Diverticulitis
31
DiverticulitisTreatment

• Hinchey staging
• Stage I
• Colonic inflammation
• Pericolic abcess
• Stage II
• Colonic inflammation
• Retroperitoneal or
• Pelvic abcess
• Stage III
• Purulent peritonitis
• Stage IV
• Fecal peritonitis

• Percutaneous drainage?
• If not.
• Sigmoid colectomy w/ primary anastamosis
• Stage I or II
• Sigmoid colectomy w/ hartman pouch
• Larger abcesses

Brunicardi, C., F., Schwartz principles of
surgery, pp 1082-1084, 8th edition, 1999
32
Festivals
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DiverticulitisReasons for Elective Surgery

• CONDITION
• Two or more severe attacks of diverticulitis (or
  one severe attack in someone younger than 50)
• Narrowing of the sigmoid colon (lower part of the
  large intestine) due to scarring
• Persistent tender mass in the abdomen
• X-ray showing suspicious changes in the sigmoid
  colon
• Pain when urinating
• Sudden abdominal pain in people taking
  corticosteroids

• REASON
• High risk of serious complications
• High risk of serious complications
• May be cancer
• May be cancer
• May be a warning of impending fistula formation
  between the large intestine and the bladder
• Large intestine may have ruptured into the
  abdominal cavity

Beers, M., 2005, Merck Manual of Medical
Information, Online version, http//www.merck.com/
mmhe/sec09/ch128/ch128c.html
34
Any questions?