Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center Diverticulitis Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center

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Diverticulitis Outline 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 Arteries penetrate the muscularis to reach the submucosa and mucosa. Diverticula form through entire colon Left colon Sigmoid (most common) Right sided (uncommon) http://health-pictures.com/diverticulitis-picture.htm Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

Diverticulitis Definition 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

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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 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 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 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

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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 Generalized peritonitis Acute abdomen Gynecologic disorders May be localized to the left lower quadrant (LLQ) Acute severe abdominal pain Perforation of an abdominal viscus Peptic ulcer Small bowel obstruction Choledocholithiasis Nephrolithiasis Rupture and dissection of an abdominal aortic aneurysm Subacute onset of pain Intestinal ischemia Cholecystitis Pancreatitis Diverticulitis Crohn's disease Appendicitis Pain of a constant nature Inflammatory disorders Colicky pain occurs Intestinal obstruction Radiation of pain Peptic ulcer disease Biliary tract disease Shoulder pain Diaphragmatic irritation Significant vomiting is seen with pancreatitis or obstruction of the stomach or small bowel.

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

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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 Abdominal CT Test of choice May demonstrate Bowel wall thickening Abscess formation Diverticula Diagnostic barium enema Safe when carefully performed Findings include Spiculation of the mucosa Spasm Frank perforation Abscess Findings specific for diverticulitis, but may be hard to distinguish from carcinoma 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 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 Severe symptoms— (perforation, peritonitis) 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 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 Retroperitoneal or Pelvic abcess Stage III Purulent peritonitis Stage IV Fecal peritonitis Percutaneous drainage? If not…. Sigmoid colectomy w/ primary anastamosis Stage I or II Sigmoid colectomy w/ hartman pouch Larger abcesses Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999

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Diverticulitis Reasons for Elective Surgery CONDITION Two or more severe attacks of diverticulitis (or one severe attack in someone younger than 50) Narrowing of the sigmoid colon (lower part of the large intestine) due to scarring Persistent tender mass in the abdomen X-ray showing suspicious changes in the sigmoid colon Pain when urinating Sudden abdominal pain in people taking corticosteroids REASON High risk of serious complications May be cancer May be a warning of impending fistula formation between the large intestine and the bladder 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

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