Transcript Diverticulitis

Diverticulitis-an update
Dr Bernard Stacey
Consultant Gastroenterologist
SUHT
Aims
• The natural history of diverticular disease
• Medical treatment for the majority of patients
with diverticular disease?
• Who needs surgery?
• Is age a problem?
• What about patients with chronic LIF pain and
associated diverticular disease?
Diverticulae
• Colonic diverticula are
mucosal outpouchings
through the large bowel wall
• Often accompanied by
structural changes (elastosis
of the taenia coli, muscular
thickening, and mucosal
folding)
• Usually multiple
• Most frequently in the
sigmoid colon
Geography/Diet
• Diverticulosis is common in resource-rich
countries
• There is a lower prevalence of diverticulosis in
Western vegetarians consuming a diet high in
fibre
• Diverticulosis is almost unknown in rural Africa
and Asia
Spectrum of presentation
• Majority of people with colonic diverticula are
asymptomatic
= Diverticulosis
• 20% develop symptoms at some point
= Diverticular disease
• When diverticulum becomes acutely inflamed
=Acute diverticulitis
Complex Colonic Diverticular Disease
Jacobs D. N Engl J Med 2007;357:2057-2066
Complications
• Complications of diverticular disease
– perforation
– obstruction
– haemorrhage
– fistula formation
are each seen in about 5% of people with colonic diverticula
when followed up for 10–30 years
• UK incidence of perforation is 4 cases/100,000 people
a year, leading to approximately 2000 cases annually
Prevalence of Diverticulosis
•
•
•
•
5% to 10% before age 50
30% after age of 50
50% over age70
66% over age 85
Natural history of diverticular disease of the colon
Parks TG
Hinchey Classification Scheme
Hinchey 1 - peri-diverticular
abscess within the mesocolon
Hinchey II - distant (pelvic,
retroperitoneal) abscess
Hinchey III - generalized
purulent peritonitis
Hinchey IV – generalised faecal
peritonitis
Jacobs D. N Engl J Med 2007;357:2057-2066
How to treat?
• If can tolerate fluids and have no peritonitis
– Fluids or Low residue liquid diet
– Pain relief
– Antibiotics (7-10 days) of oral broad spectrum antimicrobial
therapy – ciprofloxacin and metronidazole
– Need imaging of bowel to exclude other pathology (10%)
• Management can be repeated
• Consider hospital if unable to tolerate fluids, cannot
manage pain, fails to improve or has complicated
diverticulitis
Acute hospital admission
• Drip (+/- suck)
• IV antibiotics
• CT
– high sensitivity – 93-97%
– specificity – 100%
• Barium enema / colonoscopy / flex sig to check
for other pathology (avoid for 6 weeks)
CT Scans of the Colon in Four Patients with Diverticulitis of
Varying Severity
Who needs operation?
• Hinchey I - conservative
• Hinchey II distal or large abscess > 4cm: CT
drainage
– Less than 10% of Hinchey I and II need operation
• Hinchey III – usually operation
• Hinchey IV – always operation
Outcome at presentation– Hinchey
stage
Risk of death:
• <5% for most patients with stage 1 or 2
• 13 % for stage 3
• 43% for stage 4
Does one or more attacks predict
further or more serious ones?
NO
• >50% of patients presenting to hospital with
complicated diverticular disease - first
presentation
• 70% of these will have perforation
What happens after first attack?
• Recurrent diverticulitis is observed in 7–42%
• 2551 patients followed up over 9 years – 13%
recurrent attacks and 7% required surgery
• 10% recurrence in 1st year and 3% each year
afterwards
Medical treatment
• Fibre
– Lancet 1977 Broadribb
– 18 patients single randomised controlled trial with crossover.
Stopped at 3 months
– Caused a reduction in symptoms!
• Probiotics
– 2 small trials
– Longer remission
• 5ASA
– 3 trials
– Reduce peridiverticular inflammation
Patients over 75 years old
Age <75
Age >= 75
No of
colectomies
In hospital death
9458
2532
4%
13%
1 year mortality
4%
18%
Discharged home
61%
27%
10 days
13 days
Median stay
1999-2001 data from California
Parikh and Ko ASCRS 2008
Disease progression
• Inflammation will develop in 10–25% of people
with diverticula at some point
• Even after successful medical treatment of acute
diverticulitis, almost two thirds of people suffer
recurrent pain in the lower abdomen
Spectrum of symptoms with IBS
• People with uncomplicated diverticular disease
may report
– abdominal pain (principally colicky left iliac fossa
pain)
– bloating
– altered bowel habit
– may have mild left iliac fossa tenderness on
examination.
To operate or not?
• Decreasing morbidity and mortality with
laparoscopic colonic surgery
• Some cases of chronic pain and recurrent attacks
do extremely well
• Need to ‘earn’ their surgery and understand the
risks
Summary
• Most people in the Western World will develop
diverticulae
• Most will remain asymptomatic
• The most serious complication is faecal
perforation (43% mortality) – most likely to
occur at first attack
• After first attack of complicated diverticulitis
10% recur in the first year – then 3% per year
Summary
• If can tolerate fluids
– Treat at home with fluids, antibiotics for 7-10 days
and then put on fybogel, probiotics and ?ASA
• If cannot manage pain relief or fluids, or patient
sick admit
• 2 attacks no longer means surgery
• Tailor on-going management plan according to
patient needs
Conclusion
• Perforated diverticulitis kills but we cannot
predict the group in whom this occurs
• Surgery kills – must think carefully before doing
surgery