Transcript Diverticulitis - Maggie Gordon

Diverticular Disease
Maggie Gordon, R1
September 5, 2006
Outline
The disease
Treatment guidelines
The Disease
Definitions
 Colonic diverticulum: herniation of mucosa
and muscularis mucosa through colonic wall
(technically, a false diverticulum)
 Diverticulosis: presence of diverticula without
inflammation
 Diverticular disease: presence of symptomatic
diverticula
 Diverticulitis: inflammation and infection
associated with diverticula
Schwartz's Principles of Surgery - 8th Ed. (2005)
Uncomplicated Diverticulitis
Infection, inflammation of diverticulum
Presentation:
LLQ pain, tenderness
CT:
pericolic soft-tissue stranding
colonic wall thickening
phlegmon
Schwartz's Principles of Surgery - 8th Ed. (2005)
Complicated Diverticulitis
Abscess
Obstruction
Diffuse peritonitis (free perforation)
Fistulas, e.g., colovesical, colovaginal,
coloenteric, colocutaneous
Haemorrhage
Schwartz's Principles of Surgery - 8th Ed. (2005)
Complicated Diverticulitis, Abscess
Hinchey Stage
I
pericolic abscess
II
retroperitoneal or pelvic abscess
III
purulent peritonitis
IV
fecal peritonitis
Schwartz's Principles of Surgery - 8th Ed. (2005)
Epidemiology
very common in Western world
~50% people > 50 y.o.
Schwartz's Principles of Surgery - 8th Ed. (2005)
Risk Factors
age
low-fibre diet
obesity
physical inactivity
left-sided colon cancer
Ehlers-Danlos, Marfan’s, polycystic kidney
diseases
Rabinovitch, “Diverticular disease of the colon”, 2005
Etiology
 fibre diet
 stool volume
 intraluminal pressure
 colonic wall tension
 age
 tensile strength
 elasticity
muscular hypertrophy,
pulsion diverticula
Schwartz's Principles of Surgery - 8th Ed. (2005), Lawrence Essentials of General Surgery, 2000
Pathophysiology
Up To Date, 2003
Pathophysiology
Up To Date, 2003
Investigations
Townsend: Sabiston Textbook of Surgery,
17th ed., 2004
Schwartz's Principles of Surgery - 8th Ed. (2005)
Investigations - CT
Air-filled diverticula
Mesenteric stranding
www.medcyclopaedia.com
Investigations - CT
Air in bladder
Thickened wall
www.medcyclopaedia.com
Natural History
Up To Date, 2003
Natural History
Up To Date, 2003
Natural History
Attacks
1
2
3
Recurrence risk
25%
50%
“increases”
Townsend: Sabiston Textbook of Surgery, 17th ed., 2004
Treatment Guidelines
Uncomplicated Diverticulitis
Acute
Bowel rest
iv antibiotics
Merperidine better than morphine
3 weeks later
Scope to rule out cancer
4-6 weeks later
Elective resection, if appropriate…
Townsend: Sabiston Textbook of Surgery, 17th ed., 2004
SSAT Recommendations
Indications for elective operation
≥ 2 acute attacks, successfully treated
medically
one attack requiring hospitalization in
patient < 40 y.o.
one complicated attack
one attack in immunocompromised patient
inability to rule out colonic carcinoma
www.ssat.com/cgi-bin/divert.cgi
Complicated Diverticulitis, Abscess
Hinchey Stages I (pericolic abscess) and II
(retroperitoneal or pelvic abscess)
 Pre-op CT-guided percutaneous drainage
 Elective resection, primary re-anastomosis
Hinchey Stage III (purulent peritonitis)
 Emergent Hartmann’s procedure, or
 Emergent resection, primary re-anastomosis
Hinchey Stage IV (feculent peritonitis)
 Emergent Hartmann’s procedure
Conyers, “Diverticulitis. To cut or not to cut?”, 2005
Complicated Diverticulitis, Fistula
Treat acute attack
Elective resection, primary re-anastomosis
Colovesical fistula
Foley x 7-10 days
Townsend: Sabiston Textbook of Surgery, 17th ed., 2004
Complicated Disease, Haemorrhage
Resuscitation
If bleeding persistent, recurrent:
Emergent / elective resection, primary reanastomosis
Schwartz's Principles of Surgery - 8th Ed. (2005)