H.K. Oh M.D. Department of General Surgery Diverticular Disease H.K. Oh M.D. Department of General Surgery

Overview A diverticulum is an abnormal sac or pouch protruding from the wall of a hollow organ. Diverticula ; pouches Diverticulosis ; condition of having diverticula Diverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution. Decreased consumption of unprocessed cereals along with the increased consumption of sugar and meat The formation of diverticula is also related to aging Rare in individuals younger than the age of 30 years, but at least two thirds of Americans will have developed colonic diverticula by the age of 80.

Pathogenesis Diverticula are actually herniations of mucosa through the colon at sites of penetration of the muscular wall by arterioles On the mesenteric side of the antimesenteric teniae Sigmoid colon The most common site (50%) The smallest luminal diameter. Low fiber diet -> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall

Diverticular bleeding The most common cause of hematochezia in patients over the age of 60 20% of patients with diverticulosis will have GI bleeding. Risk factor ; HT, Artherosclerosis, NSAID Usually self limited, but rebleeding risk (25%) Localization ; Colonoscopy, Angiography Surgery Unstable hemodynamics, 6-unit bleed within 24 hr Without localization ; Total colectomy

Diverticulitis Definition Presentation Inflammation of a diverticulum, is related to the retention of particulate material within the diverticular sac and the formation of a fecalith Actually an extraluminal pericolic infection caused by the extravasation of feces through the perforated diverticulum Presentation LLQ pain : may radiate to the suprapubic, groin, back Bowel habit change, Anorexia, Fever, Chill, Urinary urgency

Diverticulitis Physical Findings Dependent on the site of perforation, the amount of contamination, and the presence or absence of secondary infection of adjacent organs Tenderness, Muscle guarding Tender mass : phlegmon or abscess Abdominal distension : ileus or obstruction Tender fluctuant pelvic mass on rectal or vaginal exam

Diverticulitis Diagnostic Tests CT MRI, US The preferred test to confirm the suspected diagnosis Location of infection, extent of inflammatory process, presence and location of an abscess, secondary complications sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ± the collection of contrast material or fluid MRI, US Water soluble contrast enema Distinguish acute diverticulitis from perforated cancer Risk of increasing the colonic pressure, extravasation of feces through the perforated diverticulitis

Uncomplicated Diverticulitis Disease not associated with free intraperitoneal perforation, fistula formation, or obstruction Nonoperative treatment Bowel rest + Antibiotics ; 75% response Trimethoprim/sulfamethoxazole or ciprofloxacin and metronidazole ; aerobic gram-negative rods and anaerobic bacteria The addition of ampicillin to this regimen for nonresponders ; enterococci Single-agent therapy ; a third-generation penicillin such as piperacillin The usual course of antibiotics is 7 to 10 days

Uncomplicated Diverticulitis Investigative studies After the symptoms have subsided for at least 3 weeks To establish the presence of diverticula and to exclude cancer, which can mimic diverticulitis Colonoscopy > Barium enema Recurrent disease Second attack (<25%) -> Third attack (>50%) Elective resection After infection control ; usually 4 to 6 weeks after the episode Laparoscopic resection ; growing trend Immunocompromised patient : after single attack

Complicated Diverticulitis Hinchey classification Stage I: Pericolic or mesenteric abscess Stage II: Walled-off pelvic abscess Stage III: Generalized purulent peritonitis Stage IV: Generalized fecal peritonitis

Complicated Diverticulitis Abscess Usually confined to the pelvis Significant pain, fever, and leukocytosis More than 2cm ; should be drained Percutaneous or transanal > laparotomy Elective surgery ; after 6weeks following drainage Complete removal of the entire abnormally thickened bowel

Complicated Diverticulitis Fistula Skin, bladder, vagina, or small bowel Sigmoid-vesical fistula Pneumaturia, fecaluria, and recurrent UTI (Urosepsis) CT ; may demonstrate air in the bladder Barium enema, IVP, Cystoscopy Treatment Initial treatment ; infection control and reduce the associated inflammation Rarely a cause for emergency surgery Diagnostic steps such as coloscopy should be taken to confirm the cause of the fistula before a definitive operation is undertaken.

Generalized Peritonitis Mechanism Perforation without sealing by the body’s normal defenses -> contaminated with feces Abscess burst into the unprotected peritoneal cavity -> contaminated with enteric bacteria Immediate operative intervention Excise the segment of colon containing perforation and construct a colostomy using noninflammed colon Peritoneal cavity irrigation, iv antibiotics Colostomy repair Usually after a period of at least 10 weeks

Diverticulosis in Korea Characteristics Low incidence, but increasing Rt colon (over 60%) > Lt colon Young Age, Man, Congenital, Solitary, True type, Uncomplicated type Differential Diagnosis from Acute Appendicitis RLQ pain ; first symptom site, long duration Nausea, vomiting ; absent or low Previous appendectomy Known diverticulosis (Barium enema, Colonoscopy) Fecalith Age ; 30~40 year old (later than appendicitis) History of lower GI bleeding

References Sabiston Textbook of Surgery 17ed Harrison’s Principles of Internal Medicine 16th Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current management of diverticulitis. Curr Surg. 2004 Jul-Aug;61(4):361-5 Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg. 2004 Dec;199(6):904-12. Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate? Surgery. 2004 Oct;136(4):725-30. Park JK et al. Clinical analysis of right colon diverticulitis. J Korean Surg Soc 2003 Jan;64:44-48 Chang JH et al. Surgical treatment of the colonic diverticulosis. J Korean Surg Soc 2002 May;62:415-420

Thank you for your attentions.