Diverticulitis-an Diverticulitis-an updateupdate

Dr Bernard StaceyDr Bernard Stacey

Consultant Consultant GastroenterologistGastroenterologist

SUHTSUHT

AimsAims

• The natural history of diverticular The natural history of diverticular diseasedisease

• Medical treatment for the majority of Medical treatment for the majority of patients with diverticular disease?patients with diverticular disease?

• Who needs surgery?Who needs surgery?• Is age a problem?Is age a problem?• What about patients with chronic LIF What about patients with chronic LIF

pain and associated diverticular pain and associated diverticular disease?disease?

DiverticulaeDiverticulae• Colonic diverticula are Colonic diverticula are

mucosal outpouchings mucosal outpouchings through the large bowel through the large bowel wallwall

• Often accompanied by Often accompanied by structural changes structural changes (elastosis of the taenia (elastosis of the taenia coli, muscular coli, muscular thickening, and mucosal thickening, and mucosal folding) folding)

• Usually multipleUsually multiple• Most frequently in the Most frequently in the

sigmoid colonsigmoid colon

Geography/DietGeography/Diet

• Diverticulosis is common in Diverticulosis is common in resource-rich countriesresource-rich countries

• There is a lower prevalence of There is a lower prevalence of diverticulosis in Western vegetarians diverticulosis in Western vegetarians consuming a diet high in fibreconsuming a diet high in fibre

• Diverticulosis is almost unknown in Diverticulosis is almost unknown in rural Africa and Asia rural Africa and Asia

Spectrum of presentationSpectrum of presentation

• Majority of people with colonic diverticula Majority of people with colonic diverticula are asymptomatic are asymptomatic

= Diverticulosis= Diverticulosis

• 20% develop symptoms at some point 20% develop symptoms at some point = Diverticular disease= Diverticular disease

• When diverticulum becomes acutely When diverticulum becomes acutely inflamedinflamed

=Acute diverticulitis=Acute diverticulitis

Jacobs D. N Engl J Med 2007;357:2057-2066

Complex Colonic Diverticular Disease

ComplicationsComplications

• Complications of diverticular disease Complications of diverticular disease – perforation perforation – obstructionobstruction– haemorrhagehaemorrhage– fistula formation fistula formation

are each seen in about 5% of people with colonic are each seen in about 5% of people with colonic diverticula when followed up for 10–30 yearsdiverticula when followed up for 10–30 years

• UK incidence of perforation is 4 UK incidence of perforation is 4 cases/100,000 people a year, leading to cases/100,000 people a year, leading to approximately 2000 cases annuallyapproximately 2000 cases annually

Prevalence of DiverticulosisPrevalence of Diverticulosis

• 5% to 10% before age 50 5% to 10% before age 50 • 30% after age of 50 30% after age of 50 • 50% over age70 50% over age70 • 66% over age 85 66% over age 85

Natural history of diverticular disease of the colonParks TG

Jacobs D. N Engl J Med 2007;357:2057-2066

Hinchey Classification Scheme

Hinchey 1 - peri-Hinchey 1 - peri-diverticular abscess diverticular abscess within the mesocolonwithin the mesocolon

Hinchey II - Hinchey II - distant distant (pelvic, retroperitoneal) (pelvic, retroperitoneal) abscessabscess

Hinchey III - Hinchey III - generalized generalized purulent peritonitis purulent peritonitis

Hinchey IV – generalised Hinchey IV – generalised faecal peritonitisfaecal peritonitis

How to treat?How to treat?

• If can tolerate fluids and have no peritonitisIf can tolerate fluids and have no peritonitis– Fluids or Low residue liquid dietFluids or Low residue liquid diet– Pain reliefPain relief– Antibiotics (7-10 days) of oral broad spectrum Antibiotics (7-10 days) of oral broad spectrum

antimicrobial therapy – ciprofloxacin and antimicrobial therapy – ciprofloxacin and metronidazolemetronidazole

– Need imaging of bowel to exclude other pathology Need imaging of bowel to exclude other pathology (10%)(10%)

• Management can be repeatedManagement can be repeated• Consider hospital if unable to tolerate fluids, Consider hospital if unable to tolerate fluids,

cannot manage pain, fails to improve or has cannot manage pain, fails to improve or has complicated diverticulitiscomplicated diverticulitis

Acute hospital admissionAcute hospital admission

• Drip (+/- suck)Drip (+/- suck)• IV antibioticsIV antibiotics• CT CT

– high sensitivity – 93-97%high sensitivity – 93-97%– specificity – 100%specificity – 100%

• Barium enema / colonoscopy / flex Barium enema / colonoscopy / flex sig to check for other pathology sig to check for other pathology (avoid for 6 weeks)(avoid for 6 weeks)

CT Scans of the Colon in Four Patients with Diverticulitis of Varying Severity

Who needs operation?Who needs operation?

• Hinchey I - conservativeHinchey I - conservative• Hinchey II distal or large abscess > Hinchey II distal or large abscess >

4cm: CT drainage4cm: CT drainage– Less than 10% of Hinchey I and II need Less than 10% of Hinchey I and II need

operationoperation

• Hinchey III – usually operationHinchey III – usually operation• Hinchey IV – always operationHinchey IV – always operation

Outcome at presentation– Outcome at presentation– Hinchey stageHinchey stage

Risk of deathRisk of death::• <5% for most patients with stage 1 <5% for most patients with stage 1

or 2 or 2 • 13 % for stage 313 % for stage 3• 43% for stage 443% for stage 4

Does one or more attacks Does one or more attacks predict further or more predict further or more

serious ones?serious ones?

NONO

• >50% of patients presenting to >50% of patients presenting to hospital with complicated hospital with complicated diverticular disease - first diverticular disease - first presentationpresentation

• 70% of these will have perforation70% of these will have perforation

What happens after first What happens after first attack?attack?

• Recurrent diverticulitis is observed in 7–Recurrent diverticulitis is observed in 7–42% 42%

• 2551 patients followed up over 9 years – 2551 patients followed up over 9 years – 13% recurrent attacks and 7% required 13% recurrent attacks and 7% required surgerysurgery

• 10% recurrence in 1st year and 3% each 10% recurrence in 1st year and 3% each year afterwardsyear afterwards

Medical treatmentMedical treatment• FibreFibre

– Lancet 1977 BroadribbLancet 1977 Broadribb– 18 patients single randomised controlled trial 18 patients single randomised controlled trial

with crossover. Stopped at 3 monthswith crossover. Stopped at 3 months– Caused a reduction in symptoms!Caused a reduction in symptoms!

• ProbioticsProbiotics– 2 small trials2 small trials– Longer remissionLonger remission

• 5ASA5ASA– 3 trials3 trials– Reduce peridiverticular inflammationReduce peridiverticular inflammation

Patients over 75 years Patients over 75 years oldold

Age <75Age <75 Age >= 75Age >= 75

No of No of colectomiescolectomies

94589458 25322532

In hospital In hospital deathdeath

4%4% 13%13%

1 year 1 year mortalitymortality

4%4% 18%18%

Discharged Discharged homehome

61%61% 27%27%

Median stayMedian stay 10 days10 days 13 days13 days

1999-2001 data from California1999-2001 data from California

Parikh and Ko ASCRS 2008Parikh and Ko ASCRS 2008

Disease progressionDisease progression

• Inflammation will develop in 10–25% Inflammation will develop in 10–25% of people with diverticula at some of people with diverticula at some pointpoint

• Even after successful medical Even after successful medical treatment of acute diverticulitis, treatment of acute diverticulitis, almost two thirds of people suffer almost two thirds of people suffer recurrent pain in the lower abdomenrecurrent pain in the lower abdomen

Spectrum of symptoms Spectrum of symptoms with IBSwith IBS

• People with uncomplicated People with uncomplicated diverticular disease may report diverticular disease may report – abdominal pain (principally colicky left abdominal pain (principally colicky left

iliac fossa pain)iliac fossa pain)– bloatingbloating– altered bowel habitaltered bowel habit– may have mild left iliac fossa may have mild left iliac fossa

tenderness on examination. tenderness on examination.

To operate or not?To operate or not?

• Decreasing morbidity and mortality Decreasing morbidity and mortality with laparoscopic colonic surgerywith laparoscopic colonic surgery

• Some cases of chronic pain and Some cases of chronic pain and recurrent attacks do extremely wellrecurrent attacks do extremely well

• Need to ‘earn’ their surgery and Need to ‘earn’ their surgery and understand the risksunderstand the risks

SummarySummary

• Most people in the Western World will Most people in the Western World will develop diverticulaedevelop diverticulae

• Most will remain asymptomaticMost will remain asymptomatic• The most serious complication is The most serious complication is

faecal perforation (43% mortality) – faecal perforation (43% mortality) – most likely to occur at first attackmost likely to occur at first attack

• After first attack of complicated After first attack of complicated diverticulitis 10% recur in the first diverticulitis 10% recur in the first year – then 3% per yearyear – then 3% per year

SummarySummary

• If can tolerate fluids If can tolerate fluids – Treat at home with fluids, antibiotics for Treat at home with fluids, antibiotics for

7-10 days and then put on fybogel, 7-10 days and then put on fybogel, probiotics and ?ASAprobiotics and ?ASA

• If cannot manage pain relief or fluids, If cannot manage pain relief or fluids, or patient sick admitor patient sick admit

• 2 attacks no longer means surgery2 attacks no longer means surgery• Tailor on-going management plan Tailor on-going management plan

according to patient needsaccording to patient needs

ConclusionConclusion

• Perforated diverticulitis kills but we Perforated diverticulitis kills but we cannot predict the group in whom cannot predict the group in whom this occursthis occurs

• Surgery kills – must think carefully Surgery kills – must think carefully before doing surgerybefore doing surgery