Diverticulitis

Diverticulitis
Robert Zaid PGY-1

October 24, 2005
Genesys Regional Medical Center
Barcelona - Gaudi
Diverticulitis
Outline
Definition
Pathophysiology
Epidemiology
Clinical presentation
Differential
Imaging
Laboratory
Treatment
Reasons for surgery
Diverticulitis
Definition
Diverticula
Etiology
Outpouchings
Occur in areas weak and under
stress
Prolapse of mucosa and submucosa
may occur.
Location
http://health-pictures.com/diverticulitis-picture.htm
Arteries penetrate the muscularis to

reach the submucosa and mucosa.
Diverticula form through entire colon
Left colon
Sigmoid (most common)
Right sided (uncommon)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecils Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Definition
Diverticulitis
Fecalith becomes impacted

in a diverticulum
Erosion through the serosa
Perforation
Citadel Park
Diverticulitis
Pathophysiology
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
Diverticulitis
Pathophysiology
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, 8 th edition, 1999
Diverticulitis
Pathophysiology
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
Diverticulitis
Pathophysiology
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
La Familia
Diverticulitis
Epidemiology
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
Diverticulitis
Epidemiology
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
Diverticulitis
Clinical 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.
Diverticulitis
Clinical Manifestations
Fistulas occur in 5% of patients w/

complicated diverticulitis
Colovesical
Colovaginal
Coloenteric
Diverticulitis
Differential Diagnosis
Lower abdominal pain, fever,

and bloody diarrhea
Bacterial colitis (Shigella,
Salmonella, Campylobacter)
Ischemic colitis
Inflammatory bowel disease
Generalized peritonitis
Acute severe abdominal pain
Gynecologic disorders
May be localized to the left
lower quadrant (LLQ)
Pancreatitis
Peptic ulcer disease
Biliary tract disease
Shoulder pain
Nephrolithiasis
Intestinal obstruction
Radiation of pain
Cholecystitis
Pancreatitis
Intestinal ischemia
Inflammatory disorders
Colicky pain occurs
Intestinal ischemia
Cholecystitis
Pancreatitis
Diverticulitis
Crohn's disease
Appendicitis
Pain of a constant nature
Peptic ulcer
Small bowel obstruction
Choledocholithiasis
Nephrolithiasis
Rupture and dissection of an abdominal aortic aneurysm
Subacute onset of pain
Acute abdomen
Perforation of an abdominal viscus
Diaphragmatic irritation
Significant vomiting is seen with pancreatitis or

obstruction of the stomach or small bowel.
Diverticulitis
Laboratory
Leukocytosis
Common, nonspecific
Urinalysis
Protein or rare white blood cells may be found
Nonspecific
Fecal leukocytes
Should be sought if diarrhea is present
Candy Factory
Diverticulitis
Imaging
Abdominal radiographs
May indicate
A displaced colon
Extraluminal gas
Colonic mucosal abnormalities
More helpful in excluding other potential

causes of left lower quadrant pain.
Diverticulitis
Imaging
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.
Diverticulitis
Imaging
Computed
tomographic scan
Marked thickening of
Distal end of the
descending colon
Inflammatory changes
(straight arrow)
Extraluminal gas
(curved arrow)
Diverticulitis
Imaging
Barium Enema
Colon with sinus
formation
Shows multiple
diverticula
Communicating sinus
is clearly seen (arrow).
Diverticulitis
Imaging
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
Diverticulitis
Imaging
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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Diverticulitis
Treatment
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.
Diverticulitis
Treatment
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
Diverticulitis
Treatment
Colon carcinoma may mimic diverticulitis

Colonoscopy or sigmoidoscopy is
recommended 4-6 weeks after recovery when
surgery is not performed
Diverticulitis
Treatment
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
Diverticulitis
Treatment
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
Diverticulitis
Treatment
Hinchey staging
Stage I
Colonic inflammation
Pericolic abcess
Stage II
Colonic inflammation
Retroperitoneal or
Pelvic abcess
Stage III
Purulent peritonitis
Percutaneous
drainage?
If not.
Sigmoid colectomy w/
primary anastamosis
Stage I or II
Sigmoid colectomy w/
hartman pouch
Larger abcesses
Stage IV
Fecal peritonitis
Festivals
Diverticulitis
Reasons for Elective Surgery
CONDITION
1. Two or more severe attacks of
diverticulitis (or one severe attack
in someone younger than 50)
2. Narrowing of the sigmoid colon
(lower part of the large intestine)
due to scarring
3. Persistent tender mass in the
abdomen
4. X-ray showing suspicious changes
in the sigmoid colon
5. Pain when urinating
6. Sudden abdominal pain in people
taking corticosteroids
REASON
1. High risk of serious complications
2. High risk of serious complications
3. May be cancer
4. May be cancer
5. May be a warning of impending
fistula formation between the
large intestine and the bladder
6. Large intestine may have ruptured
into the abdominal cavity
Any questions?

Diverticulitis

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Diverticulitis

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Diverticulitis

Robert Zaid PGY-1

Arteries penetrate the muscularis to

Fecalith becomes impacted

Loss of tensile strength

Occur between tenia coli

High intraluminal pressure

Mortality and Morbidity

Constipation or loose stools may be reported

Fistulas occur in 5% of patients w/

Lower abdominal pain, fever,

Acute severe abdominal pain

Colicky pain occurs

Pain of a constant nature

Subacute onset of pain

Perforation of an abdominal viscus

Significant vomiting is seen with pancreatitis or

More helpful in excluding other potential

Diagnostic barium enema

Spiculation of the mucosa

CT and barium enema are complementary

After a few days

Severe symptoms (perforation, peritonitis)

Outpatient (mild disease)

Colon carcinoma may mimic diverticulitis

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

Early surgical consultation is important

Percutaneous catheter drainage

Some reasons for surgery

The small bowel

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