Diverticular diseaseDr nawin kumar

• from the oesophagus to the rectosigmoid. • Types

1. Congenital or true- 3 layers2. Acquired or false- lacks a proper muscular coat

Small intestine

• Mesenteric side• mucosal herniation through the point of entry

of blood vessels.

Duodenal diverticula

1. Primary- – in older patients – on the inner wall of the 2nd n 3rd parts – found incidentally – Usually asymptomatic– problems locating the ampulla during

ERCP2. Secondary

– Diverticula of the duodenal cap– from long-standing duodenal

ulceration

Jejunal diverticula• variable size and multiple• common in patients with connective

tissue disorders• Variable clinical presentation

1. Symptomless2. abdominal pain3. malabsorption syndrome-

• giving rise to anaemia, steatorrhoea, hypoproteinaemia and vitamin B12 deficiency

• resection of the affected segment with end-to-end anastomosis can be effective

4. acute abdomen 1. acute inflammation2. Perforation.

Meckel’s diverticulum

Diverticulosis of colon

• outpouchings of the mucous membrane• ‘false’ diverticula• most commonly found in the descending and

sigmoid colon• occur at weak points in the circular muscle

layer, where the blood vessels supply the mucosa

• ‘Disease of The Western World’

• 60% over the age of 60 years• Rare before 40

• Affects more to females

• most commonly found in the descending and sigmoid colon

• Recum spared

• Rare in asian n african• In Asia right-sided diverticular 2x

Saint’s triad

• Diverticulosis • hiatus hernia • gall stones

Aetiology

• Why colon is common site

Laplace law

The larger the vessel radius, the larger the wall tension required to withstand a given internal fluid pressure.

Aetiologya weak colonic wall and High intraluminal pressure

weak colonic wall

• anatomic features intrinsic to the colon

– Longitudinal layer

• alterations in colonic wall with aging

• Genetically weak colonic wall – defects in collagen consistency

High intraluminal pressure

• factors–Physiological factors

• Motor dysfunction• Lower colonic motility• Colonic wall compliance • Abnormal intraluminal pressures

–Dietary factors • Diet low in fibre • Chronic constipation

• Low-fibre diets distend the colon less than high-fibre diets high intramural pressures.

• Refined, low-fibre diets may also relate to muscle spasm and muscular hypertrophy of the wall of the sigmoid colon high intraluminal pressures.

Aetiology

• Other factors– Alcohol– smoking– Corticosteroid therapy

result

–herniation of the mucosa between the taenia coli at sites of least resistance (where blood vessels pierce the circular muscle.)

– They tend to occur in rows between the strips of longitudinal muscle, some-times partly covered by appendices epiploicae

stages

diverticulosis

• 90%• Asymptomatic• Vague complain-

– Discomfort– Fullness– Bloating– flatulance

• x ray- Saw tooth appearance

spectrum of diverticular disease

• Diverticulitis• Pericolic abscess• Peritonitis• Intestinal obstruction-

– In sigmoid -progressive fibrosis causing stenosis– In small intestine - adherent loops to pericolitis

• Haemorrhage• Fistula formation

Acute diverticulitis

• Faeces obstructs the neck of a diverticulum inflammation.

Acute diverticulitis • ‘left-sided appendicitis’• Change in bowel habit eg.constipation• Bloody or purulent stool• pain- colicky abdominal pain• Tenderness- suprapubic, shifting to left iliac

fossa.• Local signs of peritonitis• Mass- tender, firm,nonmobile,resonant• Fever, nausea and vomiting • raised WCC

Aetiology "Thumbprinting" is a

radiological sign of thickening of the colonic wall (seen in left mid quadrant on this plain abdominal radiograph). It occurs secondary to submucosal haemorrhage oedema from capillary leakage. It can occur due to anything that leads to oedema of the bowel, including diverticular disease.

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Pathogenesis• Thickening of the bowel wall in

the descending colon due to bowel oedema can be seen in the left lower quadrant on this CT scan from a 62 yr old patient with diverticulitis. The hypodense (dark) spot in the bottom right of the edematous colonic wall is an abscess that is forming within the bowel wall.

• This is a CT scan of sigmoid diverticulitis in a 50yr old male patient with a history of diverticulosis and left lower abdominal pain and tenderness.

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Presentation

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Presentation• Patient presents with complications of

diverticular disease, acute - chronic. • Acute diverticulitis - Faeces obstructs the neck

of a diverticulum inflammation.- Marked by suprapubic pain, shifting to left iliac fossa.- Fever, nausea and vomiting. - ‘left-sided appendicitis’. - Local signs of peritonitis, colicky abdominal pain, raised WCC. - Change in bowel habit eg.constipation.

• Perforated diverticulitis - Sudden onset of pain with generalised peritonitis. - Shocked- Free gas on erect chest X-ray.

• Diverticular abscess - Perforated diverticulum contained by anatomical structures local abscess.- Abdominal mass on examination.

• Fistulas – most commonly with bladder.- Colovesical fistula; cystitis, pneumaturia, recurrent UTIs and faecal debris in the urine. - Colovaginal fistula; faecal discharge per vagina.- Fistula with the small intestine diarrhoea.

• Haemorrhage - Diverticula erode into adjacent blood vessels. - Sudden rush of bright or dark red blood per rectum.- Usually painless.

Investigations• [Abdominal X-ray, barium

study]• Flexible sigmoidoscopy can

visualise colonic diverticula. Colonoscopy may also be able to visualise affected segments, but the sigmoid colon is often rigid and narrow in diverticular disease which can make it hard for the scope to progress.

• Barium enemas show diverticula as globular outpouchings on X-ray film. They typically have a signet-ring appearance due to the filling defect produced by contained faecoliths.

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Investigations• Diverticular strictures can

simulate annular carcinomas on barium X-ray as both have an ‘apple-core’ appearance. Therefore an endoscope is also needed for confirmation.

• Diverticulosis- barium enema (colonoscopy)

• Diverticulitis- FBC, WCC, U+E, chest x-ray, CT scan

• Diverticular mass/paracolic abscess- CT scan

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Investigations

• Perforation- plain film of abdomen, erect chest X-ray, CT scan

• Obstruction- gastrograffin or dilute barium enema, colonoscopy to exclude underlying malignancy. Acute obstruction requires a laparotomy to establish the diagnosis of diverticulitis.

• Fistula;colovesical- MSU, cystoscopy, barium enemacolovaginal- colposcopy, flexible sigmoidoscopy

• Haemorrhage- colonoscopy, selective angiography

Management• Diverticulosis managed with dietary advice (increased fibre, increased

fluids).• Uncomplicated symptomatic disease managed similarly, with a well-

balanced diet and smooth-muscle relaxants if necessary. • Anti-spasmodics sometimes helpful. • Avoid stimulants.• Anastamoses for bowel resection must be made with rectum to avoid

recurrence • Acute attacks of diverticulitis treated with cephalosporin and

metronidazole.- Serious cases may require hospital admission for bowel rest, i.v fluids, and antibiotic therapy.

• Diverticular abscesses initially managed as above.- Paracolic abscesses can purulent / faeculent peritonitis. Usually drained surgically / under radiological guidance.-Sometimes need resection and Hartmann’s procedure.

Management• Perforated diverticulitis usually needs a laparotomy for diagnosis

confirmation.- Also for washing-out contamination from abdominal cavity and resection of sigmoid colon.- Hartmann’s procedure with temporary left iliac fossa colostomy.

• Acute obstruction requires resection of the affected segment of colon (bowel brought out as end colostomy).

• Fistula formation requires an elective colectomy and closure of the fistula.• Haemorrhages usually stop spontaneously.

- Angiography and bowel resection may be needed.• Post-inflammatory strictures may require elective resection of colon.

- If no acute inflammation or abscesses present, can perform a primary anastamosis. - Biopsy all colonic strictures to exclude underlying carcinoma.

Course & Prognosis• 10-20% of patients experience complications,

mainly diverticulitis and lower GI bleeding.• Conservative management of diverticular disease is preferred.• Surgery reserved for major complications.• In UK, surgery usually for cases of diverticular disease fistulas,

obstruction, haemorrhage or recurrent inflammation.• The Hinchey staging system used to reflect surgical outcome and risk of

secondary complications after managing the acute episode of diverticular disease.

• 33% of patients with a first attack of diverticulitis will have a recurrence. • 2-3 recurrences within 2 years are an indication for removal of the

affected colonic segment. • The prognosis for diverticular disease is good with early detection and

treatment of complications.

• 80-85 % of patients with DD remain asymptomatic

• 15-20 % of patients presenting abdominal pain /complication

Complications

• Diverticulitis• Peridiverticulitis• Pericolic/Paracolic abscess• Bleeding • Intestinal obstruction

Complications

• Fistula –Colovesical–Coloenteric –Colocutaneous–Colovaginal

Diverticulitis

–Severe pain–Recurrent episodes –Guarding and rigidity –Perforation –frank peritonitis–Fecal peritonitis

Peridiverticulitis

• Fever • Pain • Inflammatory mass• Organized perforated diverticuli

Peridiverticulitis

• Paracolic abscess• Leads to fistula

Investigations

• Colonoscopy • Barium enema • CT scan • Investigations (same as

LOWER GI BLEED)