WHY DISCUSS DIV.ITIS ? hospital admissions (NL)

In the USA from 1998 to 2005 a 26 % increase in div-itis (mostly in18-44 year old group).

A diverticulum is an pouching out of the mucosa of the gut through the muscularis externa the diverticula are in fact pseudo- diverticula. Meckels diverticulum is a true diverticulum

prevalence diverticula 40 year 5 % 60 year 30% 85 year 65 %

Causes of diverticula low fibre diet to little mobility to little fluid in diet smoking obesitas (BMI> 22.5 !)

inflammation of a diverticulum local changes of wall; hypertrofy (?) local neurological changes ( lower motility+higher pressure) (?) impaction of faeces in diverticulum -->necrosis of wall --> translocation of bacteria--> inflammation

uncomplicated Diverticulitis

investigation history (comorbidity, immune depressed, medication) ( no vomiting !) physical examination (temperature > 38.5C pain,tenderness, peritonitis?) total blood( leucocytosis) and CRP >50 mg/L this together gives an accurate diagnosis in %

In 75 % of the patients there is no diagnosis possible without imaging.

more investigation ? ultrasound ? CT scan ? endoscopy ?? MRI??

Ultrasound of diverticulitis

sensitivity and specificity of US is 90 % if US is inconclusive then CT

CT scan

sens. and specificity of CT is 95 and 99% resp advantage of CT over US is that other diagnosis can be made when there is no diverticulitis

MRI ? expensive and time consuming sens. and spec. 85 and 100 % resp. no X rays

How to treat uncomplicated diverticulitis? treat the pain mild laxans (antibiotics only when infiltrates outside colon) no hospitalization no bedrest no diet measures necessary

uncomplicated means 0 and Ia in Hinchey score so: no suspicion of an abces, peritonitis, perforation or bleeding

chances for recidive after first episode 10 % chance in the first year and every year 3 % (> 50 year) total chance for recidive aprox 25 %

complicated diverticulitis Hinchey 1b, 11, 111,1V % of patients < 40 year % of complicated div-itis at first presentation

start very quickly with IV antibiotics drainage of abces > 5 cm ( CT or US guided with needle or drain) Hinchey 111 and 1V always operation bleeding :ENDOSCOPY with intervention or embolisation (CT-angio) when profuse or when failure with scope + units of blood of course when necessary

operation Hinchey 111 and 1V deviating stoma Hartmann procedure resection with primary anastomosis laparoscopic lavage with drainage of abdominal cavity

deviating stoma

Hartman procedure

resection with primary anastomosis

Laparoscopic lavage with drainage

for today the end thank for your attention