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Diverticulitis
Robert Zaid PGY-1
October 24, 2005
Genesys Regional Medical Center
Barcelona - Gaudi
Diverticulitis
Outline
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Definition
Pathophysiology
Epidemiology
Clinical presentation
Differential
Imaging
Laboratory
Treatment
Reasons for surgery
Diverticulitis
Definition
• Diverticula
– Etiology
• Outpouchings
– Occur in areas weak and under
stress
– Prolapse of mucosa and submucosa
may occur.
• Location
http://health-pictures.com/diverticulitis-picture.htm
– Arteries penetrate the muscularis to
reach the submucosa and mucosa.
– Diverticula form through entire colon
» Left colon
» Sigmoid (most common)
» Right sided (uncommon)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Definition
• Diverticulitis
– Fecalith becomes impacted
in a diverticulum
– Erosion through the serosa
• Perforation
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Citadel Park
Diverticulitis
Pathophysiology
• Diverticula
– Acquired or congenital
– Can affect small or large intestine
– May be related to an increase in intramural
pressure
– Occurs in the weakest areas of the colonic
wall
• Adjacent to the vasa recta
• Mesenteric side of the colon
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
Diverticulitis
Pathophysiology
– Theories
• Deficiency in dietary fiber
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Western diet
Decreased fecal bulk
Narrowing of the colon
Small fecal mass
» Increased intraluminal pressure needed to move
material
• Loss of tensile strength
• Decrease in elasticity
– Proof?
• High fiber diet appears to decrease incidence
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Diverticulitis
Pathophysiology
• Diverticula
– False diverticula (pulsion)
• Herniation through colonic wall
– Mucosa
– Muscularis
• Occur between tenia coli
– Points of weakness
• High intraluminal pressure
• Bleeding is self limiting
– True diverticula
• Rare and usuall congenital
• Comprise all layers of bowel wall
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Diverticulitis
Pathophysiology
• Diverticulitis
– Inflammation in and around a diverticulum
– Stagnation of nonsterile inspissated fecal material (fecalith)
• May compromise the blood supply
• Cusing inflammatory erosion of the mucosal lining
• Perforation
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Intramural abscess
Fibrinous exudate
Abscess formation
Local adhesions
Peritonitis
Sealed-off abscesses
Contained sinus tracts
Fistulas
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
La Familia
Diverticulitis
Epidemiology
• Frequency in US
– Diverticular disease
• 5% of population at age 40
• 33-50% of population older than 50
• 80% of population older than 80
– Diverticulitis
• 10-20% of patients with diverticular disease
• Frequency internationaly
• Diverticulosis occurs in 0.2% of population
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
Diverticulitis
Epidemiology
• Mortality and Morbidity
– 20% require surgical therapy
– Mortality rate of 7.7% (if peritonitis is present)
• Race
– Asians predisposed to right sided diverticulitis
• Sex
– No relationship
• Age
– Disease increases with age
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
Diverticulitis
Clinical Manifestations
• Symptoms
– Pain
• Typically located in left lower quadrant
• Subacute and constant pain
• Right sided diverticulitis can occur (congenital?)
– Fever
• Almost invariably present
• High-grade fever and sepsis
– If perforation is not contained or
– When the peritonitis is generalized
– Constipation or loose stools may be reported
– Rectal bleeding is unusual.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Clinical Manifestations
• Fistulas occur in 5% of patients w/
complicated diverticulitis
– Colovesical
– Colovaginal
– Coloenteric
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Differential Diagnosis
• Lower abdominal pain, fever,
and bloody diarrhea
– Bacterial colitis (Shigella,
Salmonella, Campylobacter)
– Ischemic colitis
– Inflammatory bowel disease
Acute severe abdominal pain
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– May be localized to the left
lower quadrant (LLQ)
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Cholecystitis
Pancreatitis
Intestinal ischemia
Inflammatory disorders
Colicky pain occurs
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Intestinal ischemia
Cholecystitis
Pancreatitis
Diverticulitis
Crohn's disease
Appendicitis
Pain of a constant nature
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• Gynecologic disorders
Peptic ulcer
Small bowel obstruction
Choledocholithiasis
Nephrolithiasis
Rupture and dissection of an abdominal aortic
aneurysm
Subacute onset of pain
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• Generalized peritonitis
– Acute abdomen
Perforation of an abdominal viscus
Nephrolithiasis
Intestinal obstruction
Radiation of pain
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Pancreatitis
Peptic ulcer disease
Biliary tract disease
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Shoulder pain
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Significant vomiting is seen with pancreatitis
or obstruction of the stomach or small bowel.
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Diaphragmatic irritation
Diverticulitis
Laboratory
• Leukocytosis
– Common, nonspecific
• Urinalysis
– Protein or rare white blood cells may be found
• Nonspecific
• Fecal leukocytes
• Should be sought if diarrhea is present
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Candy Factory
Diverticulitis
Imaging
• Abdominal radiographs
– May indicate
• A displaced colon
• Extraluminal gas
• Colonic mucosal abnormalities
– More helpful in excluding other potential
causes of left lower quadrant pain.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Imaging
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Abdominal CT
– Test of choice
– May demonstrate
• Bowel wall thickening
• Abscess formation
• Diverticula
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Diagnostic barium enema
– Safe when carefully performed
– Findings include
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Spiculation of the mucosa
Spasm
Frank perforation
Abscess
– Findings specific for diverticulitis, but may be hard to distinguish from carcinoma
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CT and barium enema are complementary
– Neither is 100% sensitive or specific.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Imaging
• Computed
tomographic scan
– Marked thickening of
• Distal end of the
descending colon
– Inflammatory changes
(straight arrow)
– Extraluminal gas
(curved arrow)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Imaging
• Barium Enema
– Colon with sinus
formation
– Shows multiple
diverticula
– Communicating sinus
is clearly seen (arrow).
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Imaging
• Endoscopic examination
– Contraindicated with diverticulitis
– Theoretical potential to exacerbate perforation
– Can detect diverticulosis before or between
attacks
• Sigmoidoscopy
– Appropriate when
• Carcinoma or
• Inflammatory bowel disease is highly suspected
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Imaging
• Colonoscope
– Wide-mouthed
openings to diverticula
– Colonoscopy may be
difficult and hazardous
when diverticula are
large enough to admit
the tip of the scope.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
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Diverticulitis
Treatment
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Mild diverticulitis
– Initially (symptoms usually disappear rapidly)
• Rest
• A liquid diet
• Oral antibiotics
– After a few days
• Soft, low-fiber diet and take a daily psyllium (i.e. metamucil) seed preparation.
– After 1 month
• A high-fiber diet can be started
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Severe symptoms— (perforation, peritonitis)
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Admitted to hospital
Intravenous fluids and antibiotics
Bedrest
Nothing by mouth until the symptoms subside
About 20% of people who have diverticulitis require surgery because the condition
does not improve.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
Diverticulitis
Treatment
• Inpatient
– Broad-spectrum antibiotics
• Third-generation cephalosporin
– Ceftriaxone 1.5mg intravenously daily
• Anaerobic coverage
– Metronidazole 250mg intravenously three times daily
– At discharge
• Oral antibiotics to complete 14 day course
• Ciprofloxacin and Metronidazole)
• Outpatient (mild disease)
– Oral antibiotics (14 days)
• Ciprofloxacin (500mg twice daily)
• Metronidazole (250mg three times daily) for 14 days
– Bowel rest
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Treatment
• Colon carcinoma may mimic diverticulitis
– Colonoscopy or sigmoidoscopy is
recommended 4-6 weeks after recovery when
surgery is not performed
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Diverticulitis
Treatment
• Early surgical consultation is important
– Especially in the presence of significant pain
or
– An acute abdomen
• Percutaneous catheter drainage
– If large abcess is present
• Temporary
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Treatment
• Some reasons for surgery
– Colonic stricture
– Bleeding
– Fistula formation to
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The small bowel
Colon
Bladder
Vagina
Surgcial resection
– Warranted in reoccurrences (1/3 of all patients)
– Sigmoid colectomy with anastamosis
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Treatment
• Hinchey staging
– Stage I
• Colonic inflammation
• Pericolic abcess
– Stage II
• Colonic inflammation
• Retroperitoneal or
• Pelvic abcess
– Stage III
• Purulent peritonitis
• Percutaneous
drainage?
• If not….
– Sigmoid colectomy w/
primary anastamosis
• Stage I or II
– Sigmoid colectomy w/
hartman pouch
• Larger abcesses
– Stage IV
• Fecal peritonitis
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Festivals
Diverticulitis
Reasons for Elective Surgery
• CONDITION
1. Two or more severe attacks of
diverticulitis (or one severe attack
in someone younger than 50)
2. Narrowing of the sigmoid colon
(lower part of the large intestine)
due to scarring
3. Persistent tender mass in the
abdomen
4. X-ray showing suspicious changes
in the sigmoid colon
5. Pain when urinating
6. Sudden abdominal pain in people
taking corticosteroids
• REASON
1. High risk of serious complications
2. High risk of serious complications
3. May be cancer
4. May be cancer
5. May be a warning of impending
fistula formation between the
large intestine and the bladder
6. Large intestine may have ruptured
into the abdominal cavity
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
Any questions?