Drexel University College of Medicine Colonic Diverticular Disease David E. Stein, MD Division of Colorectal Surgery Department of Surgery Drexel University College of Medicine

Mrs P. 64 y/o female in the ER with LLQ pain, nausea and vomiting –History –Physical –? Labs –? Work-up

Drexel University College of Medicine Diverticular Disease Diverticulum is a saccular protrusion of mucosa through the colonic wall False vs True Pulsion

Drexel University College of Medicine

Prevalence Asymptomatic diverticulosis 80 years old: two-thirds Hemorrhaging diverticulosis: 4% Diverticulitis > 5 years disease: 10% > 20 years disease: 35% Parks 1975, Kubo 1985, Horner 1958

Drexel University College of Medicine Types Asymptomatic diverticulosis Hemorrhaging diverticulosis Acute diverticulitis Subacute diverticulitis Complicated diverticulitis

Drexel University College of Medicine Asymptomatic Diverticulosis Differentiated from IBS Doubtful role for operative therapy High-fiber diet Anti-spasmodic agents

Drexel University College of Medicine Hemorrhaging Diverticulosis Management Assess hemodynamics Establish baseline laboratory values Replace volume

Drexel University College of Medicine Hemorrhaging Diverticulosis Investigations Exclude upper gastrointestinal source Proctoscopy Colonoscopy Radionuclide scintigraphy Mesenteric angiography

Drexel University College of Medicine Colonoscopy Prerequisites Active or intermittent bleeding Hemodynamically stable Tolerant of intestinal lavage Accuracy: 70-92% Amenable to therapy: 17-39% Jensen 1988, Rossini 1989, Richter 1995

Drexel University College of Medicine Radionuclide Scintigraphy Modalities Technetium-99m sulfur colloid Technetium-99m-labeled red blood cells Effectiveness Incorrect localization: 48-60% Incorrect operation: 42% Hunter 1990, Bentley 1991, Voeller 1991

Drexel University College of Medicine Mesenteric Angiography Effectiveness Localization of bleeding site: 57-72% Reduced operative mortality: 9-14% vs % Therapeutic options Vasopressin infusion Embolization Britt 1983, Browder 1986, Uden 1986, Koval 1987

Drexel University College of Medicine Mesenteric Angiography Vasopressin infusion Initial control: 70-92% Rebleed rate: 22-71% Embolization Initial control: % Rebleed rate: 0-12% Browder 1986, Guy 1992, DeBarros 1997, Szomstein 1997

Drexel University College of Medicine Hemorrhaging Diverticulosis Operative indications Persistent hypotension Transfusion requirements: – 6 units of blood over initial 24 hours – 10 units of blood Rebleeding within 7 days of cessation

Drexel University College of Medicine Acute Diverticulitis Differential diagnosis Malignancy Inflammatory bowel disease Ischemic colitis Urologic/gynecologic disorders

Drexel University College of Medicine History and Physical Patients may have antecedent history of thinning bowel movements Patients may know they have “pockets” All colonic pain is hypogastric – so bandlike pain across the lower abdomen is common No endoscopy or contrast enemas in the acute phase – CT Scan

Drexel University College of Medicine Acute Diverticulitis Investigations: Ultrasonography Water soluble contrast enema Computerized tomography (CT)

Drexel University College of Medicine Ultrasonography Diagnostic criteria Hypoechoic wall thickening, hyperechoic diverticulae, hyperechoic halo Effectiveness Positive predictive value: 96% Negative predictive value: 98% Schwerk 1992

Drexel University College of Medicine Contrast Enema Diagnostic criteria Mild: segmental narrowing, tethered mucosa, mass effect Severe: extraluminal gas/contrast Effectiveness Sensitivity: 94%; accuracy: 77% Johnson 1987, Smith 1990

Drexel University College of Medicine Contrast Enema

Drexel University College of Medicine Computerized Tomography Diagnostic criteria Mild: Localized wall thickening ( > 5 mm), pericolic fat inflammation Severe: abscess, extraluminal gas/contrast Effectiveness Sensitivity: 93-97% Cho 1990, Ambrosetti 1997

Drexel University College of Medicine Computerized Tomography

Drexel University College of Medicine Acute Diverticulitis Outpatient management Low-residue, low-fiber diet Oral antibiotics Inpatient management Bowel rest Intravenous antibiotics

Drexel University College of Medicine Acute Diverticulitis Follow-up management (6 weeks) Exclude malignancy – endoscopy – contrast enema Exclude complicated diverticulitis – contrast enema – computerized tomography

Drexel University College of Medicine Acute Diverticulitis First episode outcome Fail medical therapy: 20% Secondary complications: 20% Recurrent episode(s) outcome Secondary complications: 60% Ambrosetti 1997, Farmakis 1997, Kohler 1999

Drexel University College of Medicine Acute Diverticulitis Mild diverticulitis: Fail medical therapy: 4% Secondary complications: 14% Severe diverticulitis: Fail medical therapy: 30% Secondary complications: 39% Ambrosetti 1997

Drexel University College of Medicine Acute Diverticulitis Special circumstances Patients < 50 years of age – obese males Patients with compromised immune systems – transplant candidates Schauer 1992, Ambrosetti 1994, Vignati 1995

Drexel University College of Medicine Operative Indications Failed medical therapy Resolved first episode Severe diverticulitis Age < 50 years Current or future immunosuppression Resolved second episode Complicated diverticulitis

Drexel University College of Medicine Subacute Diverticulitis Diverticulae, pain, altered bowel habits Pathology: Acute/chronic inflammation: 82% Clinical course: Resolution of symptoms: 70% Resolution of pain: 84% Horgan 2000

Drexel University College of Medicine Complicated Diverticulitis Perforation Fistula Obstruction

Drexel University College of Medicine Perforation Considerations Stage of peritonitis Peri-operative factors Operative alternatives Outcome

Drexel University College of Medicine Staging Systems Intra-operative systems Hughes 1963 Hinchey 1978 Killingback 1983 Sher 1997 Peri-operative systems Setti Carraro 1999 Biondo 2000

Drexel University College of Medicine Hinchey Stage I Confined abscess Paracolic Intra-mesenteric Hinchey 1978

Drexel University College of Medicine Hinchey Stage II Distant abscess Pelvic Retroperitoneal Intra-abdominal Hinchey 1978

Drexel University College of Medicine Hinchey Stage III Purulent peritonitis Non-communicating Obliterated neck of diverticulum Hinchey 1978

Drexel University College of Medicine Hinchey Stage IV Fecal peritonitis Communicating Freely perforated diverticulum Hinchey 1978

Drexel University College of Medicine Peritonitis Severity Score Age Underlying disease Immunosuppressed Hinchey peritonitis score Biondo 2000 ASA score Pre-operative organ failure

Drexel University College of Medicine Preferred Staging Systems Hinchey peritonitis score American Society of Colorectal Surgeons American College of Gastroenterology Modified Hinchey peritonitis score European Association of Endoscopic Surgery Stollman 1999, Wong 2000, Kohler 1999

Drexel University College of Medicine Operative Preparation Broad-spectrum antibiotics Percutaneous drainage of abscesses Stoma marking and counseling Reversal of deficits Invasive monitoring Ureteral stents Ambrosetti 1992

Drexel University College of Medicine Diversion and Suture Closure Suture closure of perforation Omental pedicle Proximal colostomy Optional drainage

Drexel University College of Medicine Resection and Colostomy Resection of perforation Mucus fistula or closure Proximal colostomy Optional drainage

Drexel University College of Medicine Resection and Anastomosis Resection of diseased segment On-table lavage Primary anastomosis

Drexel University College of Medicine Resection and Diverted Anastomosis Resection of diseased segment On-table lavage Primary anastomosis Proximal stoma

Drexel University College of Medicine Resection and Anastomosis (I, II)

Drexel University College of Medicine Operative Alternatives (III, IV)

Drexel University College of Medicine Resection and Anastomosis (III, IV)

Drexel University College of Medicine Operative Mortalitiy (III, IV)

Drexel University College of Medicine Laparoscopy E.A.E.S. consensus statement: … in Hinchey I and II patients, the laparoscopic approach is not the first choice, but may be justified if no gross abnormalities are found … … no place today for laparoscopic resections in Hinchey III and Hinchey IV patients … Kohler 1999

Drexel University College of Medicine Summary: Hinchey Stage I 1. Non-operative management Elective resection and anastomosis Observation 2. Percutaneous abscess drainage Elective resection and anastomosis 3. Urgent laparotomy/laparoscopy Resection, lavage, and anastomosis

Drexel University College of Medicine Summary: Hinchey Stage II 1. Non-operative management and abscess drainage Elective resection and anastomosis 2. Urgent laparotomy/laparoscopy Resection, lavage, and anastomosis Resection, lavage, and diverted anastomosis

Drexel University College of Medicine Summary: Hinchey Stage III 1. Emergent laparotomy Resection and colostomy Resection, lavage, and diverted anastomosis Resection, lavage, and anastomosis Diversion and suture closure

Drexel University College of Medicine Hinchey Stage IV 1. Emergent laparotomy Resection and colostomy Resection, lavage, and diverted anastomosis

Drexel University College of Medicine Fistula Colovesical Colocutaneous Colovaginal Coloenteric

Drexel University College of Medicine Colovesical Fistula Symptoms Cystitis: 70-80% Lower abdominal pain: 30-90% Pneumaturia: 60% Fecaluria: 40-70% Bowel symptoms: 65% Pheils 1972, Woods 1988

Drexel University College of Medicine Colocutaneous Fistula Etiology: post-operative: 95%; spontaneous: 5% Signs: Fever, mass, obstruction, peritonitis, fistula Factors associated with persistent fistula Sepsis: 45% Residual sigmoid colon: 40% Crohn’s disease/carcinoma Fazio 1987

Drexel University College of Medicine Colovaginal Fistula Symptoms Abdominal pain Pus/stool/flatus passed per vagina Signs Vaginal os: ~75% Pelvic mass Woods1988

Drexel University College of Medicine Diagnosis Colovesical fistula Cystoscopy: 92% Barium enema: 5-80% Cystogram: 30% Sigmoidoscopy Computerized tomography Woods 1988

Drexel University College of Medicine Diagnosis Colocutaneous/colovaginal fistula Fistulogram Vaginogram Barium enema Endoscopy Computerized tomography

Drexel University College of Medicine Treatment Non-operative therapy Operative therapy Separation of organs by blunt dissection Primary resection Individualized repair of defect Omentopexy Amin 1984

Drexel University College of Medicine Obstruction Etiology: perforation, recurrent episodes of diverticulitis, small bowel adhesions Symptoms: abdominal pain, distention, constipation Diagnosis: water-soluble contrast enema

Drexel University College of Medicine Obstruction Non-operative therapy Operative therapy Emergent – colostomy – resection with colostomy – resection, lavage, and anastomosis +/- loop ileostomy Elective – resection with anastomosis

Drexel University College of Medicine Summary Diverticulosis is a common, age-related condition. Hemorrhaging diverticulosis usually resolves but may warrant therapeutic angiography or resection. Operative treatment of acute diverticulitis is reserved for failed therapy, first episodes with special circumstances, and most second episodes.

Drexel University College of Medicine Summary Operative treatment is warranted for most episodes of complicated diverticulitis, including perforation, fistula, and obstruction. The diseased bowel should be resected from supple colon proximally to rectum distally; excision of all diverticulae is unnecessary.

Drexel University College of Medicine Colonic Diverticular Disease David E. Stein, MD Division of Colorectal Surgery Department of Surgery Drexel University College of Medicine