Transcript Diverticular Disease

Diverticular Disease
Dr. Matt W. Johnson
Introduction & Overview
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Pathology
Physiology
Location
Complications
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Bleeding
Obstruction
Fistula
Acute Diverticulitis
• Management of Acute Diverticulitis
Pathology
• Congenital
• Acquired
– association with Western diets high in refined
carbohydrates and low in dietary fibre1
– Deficiency of vegetable fibre in diet2
– Disordered motility
– Hyperelastosis may lead to structure change
– Collagen abnormalities
– Age
• Diverticular disease occurs in over 25% of the
population, increasing with age3
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Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005
Physiology
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La Place effects
High intra-luminal pressure
Resultant characteristic protrusion mucosa
Worst at terminal arterial branches
Rectal sparing
– ?due to complete layer of longitudinal muscle and
large diameter
Physiology and Anatomy
•Terminal arterial branches
•Penetrate circular muscle
•Often lie adjacent to taenia
Location
• Classically Sigmoid
• In Orient often right-sided
• Rectal Sparing
• Can occur anywhere
(but considered separately)
e.g. Small bowel –see later
Right vs. Left
Complications
• Obstruction
• Bleeding
• Inflammation “itis”
– Fistula
– Sepsis
– Perforation
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May co-exist with IBD
Specimen showing blood in diverticulae
Obstruction in Diverticular Disease
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Progressive distension
Single contrast enema will delineate this
Often present like cancer
Diagnosis
– often only at operation (opened specimen) or
– on histology
Bleeding in Diverticular Disease
• Rarely exsanguinating
• Often requires repeat transfusion
• Consider mesenteric angiography if available
– Embolisation (risk of ischaemia and infarction)
– Allows targeted resection
• Operative intervention uncommon
– On table colonoscopy
– Exclusion
Re-Bleeding Rates
Re-bleeding rate
Year
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Percentage
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19
25
Longstreth Am J Gastro 1997
Other Causes Of Colonic Bleeding
• Exclude
–IBD
–Neoplasm
–Angiodysplasia
–Ischaemic colitis
–Radiation proctitis
– Varices
Fistula
• Abnormal connection
• Commonest communications are
– Colovesical
– Colovaginal (esp if prev TAH)
• Colovesical Symptoms
– Pneumaturia
– Recurrent infections
– Faecalent urine or particulates
• Diagnosis of site/communication vs pathology
– CD/CRC/TCC
Acute Diverticulitis
• Abscess
– Peridiverticular
– Mesenteric
– Pericolic
• Perforation
– Concealed
– Free
• Peritonitis (gangrenous sigmoididits)
– Purulent or serous or faecal
– Local or generalised or pelvic
1
Killingback Surg Clin North Am 1983
Emergency Presentation
• Symptoms
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Generally unwell
Pain localising to left iliac fossa*
Abdominal distension
Altered bowel habit e.g. diarrhoea
Nausea/Fever
• Signs
– LIF tenderness
– *Beware RIF pain-in right sided diverticulitis and
where sigmoid crosses midline
– Systemic signs (T/HR/BP/WCC)
– May be palpable on pR at anterior rectal wall
Management
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Resuscitation
Analgesia
Bloods
ECG/Catheter/Urine
Rectal examination (+/-sigmoidoscopy)
CXR
AXR
USS
CT Scan
Operative intervention
CXR
AXR
Diverticular disease
CT Scan
Perforated diverticulitis of the sigmoid colon-CT
Diverticulitis
with pericolic abscess
Operative Picture
Perforation
Operative considerations
• Serial assessment and clinical judgement
– (even if Radiological perforation)
• Operative indications
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generalized peritonitis
uncontrolled sepsis,
visceral perforation
acute clinical deterioration
• At operation
– Resection better than no resection1
– Hartmann’s vs anastomosis
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Krukowski & Matheson Br J Surg 1984
Anastomosis
• Is there any role for primary anastomosis in the inflamed
bowel?
• Consider if fully resuscitated and colorectal Surgeon
• Retrograde gun/washout kit
• Schilling et al. 2001 Diseases of the Colon and Rectum
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diverticulitis with peritonitis
13 patients one stage
42 Hartmann’s procedure
7% mortality in both groups
• Similar complication rates
– Not a study of bowel obstruction
Elective Presentation
• Via outpatients
• Often milder version of emergency
presentation
• Incidental radiological finding
– AXR
– Contrast study e.g. Barium Enema
– CT scan
• Rarely if insiduous, an abscess may be found on Barium
Enema as an outpatient
Elective resection for Diverticultis
• After recovering from an episode of diverticulitis
the individual risk of an urgent Hartmann’s is
1 in 2000 patient-years of follow-up.
• Surgery for diverticular disease has a high
complication rate
• 25% of patients have ongoing symptoms after
bowel resection (IBS/IBD)
• No evidence to support the idea that elective
surgery should follow two attacks of diverticulitis.
• Further prospective trials are required.
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Janes et al BJS 2005
Duodenal and Jejunal
Diverticulosis
• Separate from colonic diverticulosis.
• Most occur in the jejunum and occasionally duodenum.
• Jejunal diverticula are acquired protrusions of the
mucosal lining through the muscular wall of the bowel.
• Encourages particular bacterial overgrowth.
• A combination of alteration of the intraluminal contents
by these bacteria may result in malabsorption
– Calcium
– Iron
– Vitamins D or B12.
• Patients may present with anaemia and occasionally
osteomalacia.
Proximal Jejunal Diverticulitis
Incidental Jejunal Diverticular
Proximal Jejunal diverticulitis with
perforation
Questions
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