Transcript Recent developments in coeliac disease

Colonic Diverticulosis:
A review
Dr. Matt W. Johnson BSc MBBS MRCP MD
Consultant Gastroenterologist
Diverticulosis
Operative Picture
Introduction
• Diverticular ? disease
(or Variant of normal ?)
• Prevalence = 40% in those >50y
• 70% of those >80y
• 68,000 Hospital admissions / year in UK
• 2,000 deaths / year in UK
•
•
Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial
number NCT00663247. 2010
Diverticular disease and diverticulitis, Clinical Knowledge Summaries (March 2008)
Diverticulosis Demand on L&D
Services
• 70-80% of new patient clinic appointments are
for ABHs
• Over the last 7y = 12,000 FS’s
• Of these;–
–
–
–
–
5,500
500
2,000
580
500
=
=
=
=
=
Normal
Haemorrhoids
Diverticulosis
Colitis
Rectal Cancer and Polyps
47%
<5%
17%
5%
<5%
Introduction
BSG recommendation re - terminology
•
•
•
•
•
Diverticulosis
Diverticular disease Diverticulitis
Diverticular colitis
Diverticular bleeding -
Asymptomatic (75%)
Symptomatic (<25%)
Inflamed/Infected (75%)
Associated colitis
15%
Introduction & Overview
•
•
•
•
Epidemiology
Pathophysiology
Diverticulosis
Complications
–
–
–
–
–
–
Symptomatic DD
Diverticulitis
Diverticular colitis
Diverticular haemorrhage
Stricture obstruction
Fistula
• Management
Cross Sectional Bowel Anatomy
Cross Section of Diverticulae
Physiology and Anatomy
•Terminal arterial branches
•Penetrate circular muscle
•Often lie adjacent to taenia
Physiology
• High intra-luminal pressure gradient
• Weakest at the point where the terminal arterial
branches penetrate through the circular muscles.
• Rectal sparing
– ?due to complete layer of longitudinal muscle and
large diameter
Pathology
• Congenital
• Acquired - Multifactorial
– Mychosis
• Increased depositioning of collagen + elastin in taeniae = shortening
and thickening = narrowing with increased luminal pressures
– Hypersegmentation
• Non-propulsive contraction of circular muscle in closed segment =
increases luminal pressure = herniation
– Laplace’s Law
• Transmural P gradient = Wall tension ÷ radius = Sigmoid
– Structural wall abnormalities
• Ehlers Danlos, Marfan’s, PCKD - Reduced tensile strength of CT
– Dietary factors
1+2+3
• West (insoluble fibre) > East (soluble fibre) rare in Africa
• Insoluble stool fibre = increases stool bulk = larger colon diameter =
impaired segmental contractions = higher intra-luminal pressures
1
Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005
Idiopathic Slow Transit Constipation
Day 5 after taking markers
Diverticulosis
• 75% = most found incidentally
• When questioned most will have symptoms ie
= Diverticular disease
• No proven evidence that Mx helps prevent
enlargement or further development of
diverticulae
Epidemiology - Location
• Classically Sigmoid
• In Orient often right-sided
• Rectal Sparing
• Can occur anywhere
e.g. Small bowel
Diverticulosis
Right Sided
Left Sided
Diverticular Disease
•
•
•
•
Altered bowel habits (pellets / loose)
Bloating / Flatulence / Borborygmi
Incomplete evacuation
LIF discomfort relieved by defaecation
• Mx = Soften and shift stool
–
–
–
–
–
–
High fluid >2L/d
Low residue (high soluble fibre) diet
+/- Movicol 1 sachet bd
+/- Mesalazines
+/- Buscopan / Spasmolol / Colperamin / Mebeverine
Avoid opioids + Loperamide
Diverticulitis
• Cause
– Inspissation of faecal content stuck in
diverticlum
– Obstruction of the diverticulum
– Increased pressure = local ischaemia +
breakdown of mucosal barrier
– Localise bacterial overgrowth + translocation
across membrane = micro-abscesses
S+S’s of Diverticulitis
Symptoms
• LIF pain
(can be right sided)
• ABH / Diarrhoea
• N+V
Signs
• Pyrexia
• Wbc
• ESR or CRP
• CXR + AXR
• US < CT scan
(Temp > 38°C)
(>12)
(exclude complications eg. abscess)
Management
Ix
•
•
•
•
•
Bloods
Rectal examination (avoid sigmoidoscopy for 2 weeks)
CXR
AXR
USS or CT Scan
Mx
• Resuscitation IV fluids
• Antibiotics
• Analgesia
• Operative intervention
Hinchney Classification of
Diverticulitis
Grade
Extent
1
Localised
abscess
2
Abscess into
pelvis
Purulent
peritonitis
5%
Faeculant
peritonitis
43%
3
4
Hinchney EJ. AdvSurg.1978;12:85-109
Mortality
Prognosis
<5%
13%
Acute Diverticulitis
• Abscess
– Peridiverticular
– Mesenteric
– Pericolic
• Perforation
– Concealed
– Free
• Peritonitis (gangrenous sigmoidits)
– Purulent or serous or faecal
– Local or generalised or pelvic
1
Killingback Surg Clin North Am 1983
Diverticulitis
with pericolic abscess
Management of Complicated
Diverticulitis
Mild / Grade 1
• Mx = Outpatient, High fluid + low residue diet
• Rx = OP ABs 7-10d
• (Metronidazole + Co-amoxiclav or Ciprofloxacin)
• Moderate / Grade 2
• Mx = In-patient, As above
• Rx = IV Abs +/- XR guided drainage
• Severe / Grade 3+4 or with Complications
• Mx = IP Resuscitation, As above
• Rx = IV ABs + Contact Surgeons
Elective resection for Diverticulitis
• Emergency surgery for perforated Diverticulosis with peritonitis =
Mortality rate of 7% 1
• Diverticular Surgery = High complication rate 2
• For emergency surgery = Primary anastomosis
– A RMCCT found one-stage procedure (primary anastomosis)
significantly reduced rates of postoperative peritonitis and emergency
re-operation compared with a two-stage procedure (formation of an
end colostomy with oversewing of the rectal stump - Hartmann's
procedure) 3
• 25% of patients have ongoing symptoms after bowel resection
(IBS/IBD) 3
• No evidence to support elective prophylactic surgery
1 Schilling et al. 2001 Diseases of the Colon and Rectum
2
Krukowski & Matheson Br J Surg 1984
3 Janes
SE, Meagher A, Frizelle FA; Management of diverticulitis. BMJ. 2006 Feb 4;332(7536):271-5
Diverticular colitis
• Presentations
•
•
– Asymptomatic
– Bloody diarrhoea
– Abdo pain
Affects sigmoid like UC but doesn’t effect rectum
Rx = Mesalazines 1,2,3,4
1
Spiller RC. NCI00663247
2
Mario F. JClinGastro. 2006;40Suppl3:S1. 55-9
3
G. Did Dis Sci. 2007;52:2934-41
4
A. Dig Dis Sci. 2007. 2007;52:671-4
Complications of Diverticulitis
•
•
•
•
•
Bleeding1
Perforation
Obstruction
Fistulae
Abscess
(15-25%)
(25%)
• May co-exist with IBD
1
Travis S. Colonic Diverticular Disease 2005;312
Specimen showing blood in
diverticulae
Bleeding in Diverticular Disease
• 3-5% of all diverticulosis
• 15-25% of all the diverticulitis 1
• Accounts for 40% of all LGI bleeding 1
• 75-90% stop spontaneously 2
• 10-40% risk of re-bleed 2
• Morbidity + Mortality rate = 10-20% 3
1 Gostout CJ. JClinGastro. 1992;14(3):260
2 McGuire HH Jr. Ann Surg. 1994;220(5):653
3 Uden P. Dis Colon Rectum. 1986;29(9):561
Management of Diverticular Bleeds
Mx
• Resuscitation + Transfusion
• Rbc labelling scan
(0.1ml/m)
• Localisation = 24-91%
• Mesenteric angiography (0.5ml/m)
• +/- Embolism
• Endoscopic therapies
• Adrenaline +/- Endoclips
• Sx targeted resection
Re-Bleeding Rates
Re-bleeding rate
1
Year
Percentage
1
9
2
10
3
19
4
25
Longstreth Am J Gastro 1997
Other Causes Of Colonic Bleeding
• Exclude
– IBD
– Neoplasm
– Angiodysplasia
– Ischaemic colitis
– Radiation proctitis
– Varices
Perforation (35% Mortality)
CT Scan
Perforated diverticulitis
of the sigmoid colon-CT
CXR
AXR
Obstruction in Diverticular Disease
• Increased fibrotic reaction leads to stricturing
• Often present like cancer
• Progressive distension with faecal loading
• Single contrast enema will delineate this
• Diagnosis
– often only at operation (opened specimen) or
– on histology
Fistula
• Abnormal connections
• Colovaginal (esp if prev TAH)
• Colovesical
– Pneumaturia
– Recurrent infections
– Faecalent urine or particulates
Duodenal and Jejunal
Diverticulosis
•
•
•
•
Different to colonic diverticulosis.
Most occur in jejunum and (occasionally) duodenum.
Commonly associated with bacterial overgrowth.
Jejunal diverticula are acquired secondary to protrusions
of the mucosal lining through the muscular wall of the
bowel.
• Vitamin deficiencies
– Increased colonic transit = Reduced Vit D (+Ca) + Iron
– SBBO
= Reduced B12+ Increased Folate
• Patients may present with anaemia and osteomalacia.
Proximal Jejunal Diverticulitis
Incidental Jejunal Diverticular
Proximal Jejunal diverticulitis with
perforation
Further Reading
• COLONIC DIVERTICULOSIS: A REVIEW
• Tyara Banerjee,
• Suman Verma,
• Matthew W. Johnson.
• Good Clinical Care
Graham Holland’s Luton
‘the optimism and the frustration of living in a metropolis’