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Colonic Diverticular Disease (pp.

1971-1973)
Epidemiology
-

Occurs in 70% of population


age > 80
20% develop symptoms, 12% require hospitalization,
<1% require surgery
Patients often report lower
health-related quality of life,
and more depression
Prevalence is equal between
males and females
o In younger ages
predominantly males
o Mean age of
presentation is 59
years

Anatomy and Physiology


-

Two types of diverticula: true


and false/pseudo
o True diverticula
saclike herniation of
the entire bowel wall
o Pseudo diverticula
only a protrusion of the
mucosa and
submucosa through the
muscularis propria of
the colon
Most common
affecting the
colon
Diverticulitis
inflammation of the
diverticulum
o Occurs at the point
where the nutrient
artery (vasa recti)
penetrates the
muscularis propria

Factors contributing to
creation of diverticula:
o High-amplitude
contractions
o Constipation
o High-fat content stool
within the sigmoid
lumen in an area of
weakness in the colonic
wall
o Chronic low-grade
inflammation
o Dysbiosis

Presentation, Evaluation, and


Management of Diverticular
Bleeding
-

Hemorrhage most
common cause of
hematochezia in patients age
> 60
Presenting factors of
diverticular bleeding:
o Hypertension
o Atherosclerosis
o NSAID use
Usually self-limited and
stops with bowel rest; risk of
rebleeding is 25%
Localization of bleeding can
be done using:
o Colonoscopy
o Multiplanar CT
angiogram
Best
management if
patient is stable
If this localizes
the bleeding, a
coil can occlude

the bleeding
vessel
o Nuclear medicine
tagged red cell scan
Patient is followed up closely
with repetitive colonoscopy
look for evidence of
colonic ischemia
Alternative methods
(hemodynamically stable):
o Segmental resection of
colon advantageous
to those who require
constant anticoagulant
therapy
o Vasopressin infusion
stops haemorrhage but
is associated with
significant
complications
Surgery used for unstable
patients or those who had a
6-unit bleed within 24 hours
o Segmental resection
used if bleeding is
localized
o Subtotal colectomy
used if bleeding is
not definitively
identified
o Primary anastomosis
used in those
without
comorbidities

Presentation, Evaluation, and


Staging of Diverticulitis
-

Common signs: fever,


anorexia, LLQ pain, and
obstipation
Peritonitis sign that
denotes diverticular
perforation

Pericolonic abscess
presents with abdominal
distention and localized
peritonitis
Laboratory: leukocytosis

Presence of air-fluid level in


LLQ on plain film giant
diverticulum of sigmoid colon
managed with resection
Diagnosis: best made with
CT; findings include:
o Sigmoid diverticula
o Thick colonic wall > 4
mm
o Inflammation within the
periodic fat with or
without collection of
contrast material or
fluid
Mimics of diverticular disease
include:
o Irritable bowel
syndrome (IBS)
o Ovarian cyst
o Endometriosis
o Appendicitis
o Pelvic inflammatory
disease (PID)
Colonoscopy NOT used to
diagnosed BUT is used to
exclude possibility of
colorectal cancer

o Performed 6 weeks
after an attack of
diverticular disease
Complicated diverticular
disease associated with
abscess, perforation, or
fistula
o Perforation is staged
using the Hinchey
classification system

Hinch Presentation
ey
Stage
I
Perforated diverticulitis
with confined paracolic
abscess
II
Perforated diverticulitis
with distant abscess
formation
III
Noncommunicating
perforated diverticulitis
with fecal peritonitis
IV
Perforation and free
communication resulting
to fecal peritonitis

Surgical
-

o Fistula formation occurs


at the cutaneous areas,
vagina, and vesicles
Colovaginal
fistula
common in
women who
underwent
hysterectomy
Treatment
Medical
-

Asymptomatic: diet
alterations (30 g fiber/day),
stop smoking

Symptomatic: give
antibiotics and bowel rest
o Antibiotic: TMP/SMX
or Ciprofloxacin and
Metronidazole, with
Ampicillin
o Alternatively: IV
piperacillin or oral
penicillin/clavulanic
acid
o Patients kept at limited
diet until pain resolves
o Use of antiinflammatory
medications
(mesalazine)
Dysbiosis give
probiotics such as
Lactobacillus acidophilus and
Bifidobacterium

Advised for:
o For low risk patients
(ASA P1 and P2) who
do not rapidly improve
on medical therapy

o For ALL low risk


patients with
complicated
diverticular disease
For uncomplicated
diverticular disease,
perform either laparascopic

sigmoid resection or open


sigmoid resection
o Benefits of laparascopic
over open:
Early discharge
Less narcotic use
Less post-op
complications
Earlier return to
work
For complicated diverticular
disease, perform:
o Drainage, omental
pedicle graft, and
proximal diversion of
fecal stream
o Hartmanns procedure
o Sigmoid resection with
colproctostomy
o Colproctostomy and
proximal diversion
Hinchey stages I and II
managed with percutaneous
drainage followed by
resection with anastomosis
after 6 weeks
o Hartmanns
procedure if
patients manifest
peritonitis

Hinchey stage III


Hartmanns procedure or
proximal anastomosis and
proximal diversion
Hinchey stage IV NO
anastomosis of any type
should be attempted;
preferred is Hartmanns
procedure

Recurrence of Symptoms
-

Commonly due to:


o Inadequate surgical
resection
o Retained segment of
diseased rectosigmoid
colon is associated with
twice the incidence of
recurrence
o IBS poorer functional
outcome

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