1. Diverticular Disease and Hemorrhoids
Lance T. Uradomo, MD, MPH
Assistant Professor of Medicine
Division of Gastroenterology and Hepatology
University of Maryland School of Medicine
Director of Endoscopy, Baltimore VA Medical Center
Center for Cancer Surveillance and Control Teleconference
Maryland Department of Health & Mental Hygiene
January 21, 2009

2. Outline Diverticular Disease Hemorrhoids Diverticulosis Diverticulitis
Diverticular Hemorrhage
Hemorrhoids
Classification
Therapy

3. Anatomy Transverse Splenic Flexure Hepatic Flexure Descending Sigmoid
Ascending
Cecum
Rectum
Stone C.

4. Definitions
Diverticula – an abnormal pouch or sac opening from a hollow organ (as the colon or bladder)
Diverticulosis - the presence of diverticula in the colon
Diverticulitis - inflammation or infection of a diverticulum of the colon
Diverticular Disease - a disorder characterized by diverticulosis or diverticulitis
2005 Merriam-Webster, Incorporated

5. Introduction Diverticula form at weak points in the bowel wall
Often where vasa recta vessels penetrate the muscle layer
Most common in left colon (70-90%)
Asia more common in right
Stone C.

6. Epidemiology Prevalence of Diverticula Age Gender Geography
< 10% in people under 40 year old
50% to 66% over age 80
Gender
Geography
Western countries
Low prevalence in Asia and Africa
Varies by study due to asymptomatic nature
Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125

7. Pathophysiology of Diverticula
Associations with diets low in dietary fiber and high in refined carbohydrates.
Less bulky stools that retain less water and may alter gastrointestinal transit time;
Increase intracolonic pressure and make evacuation of the colonic contents more difficult.
Other factors:
physical inactivity, constipation, obesity, smoking, and treatment with nonsteroidal antiinflammatory drugs.
Jacobs DO, N Engl J Med 2007;357:

8. Symptoms of Diverticulosis
Most are asymptomatic
Some experience crampy pain or discomfort in the lower abdomen, bloating, and constipation.

9. Acute Diverticulitis Most common complication of diverticular disease
10-25% of patients
Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125

10. Pathophysiology of Diverticulitis
Fecalith
Bacterial flora
Micro or macro perforation
Not much known
Stone C.

11. Presentation of Acute Diverticulitis
Symptoms
Left lower quadrant pain
Fever
Leukocytosis
Exam
Abdominal tenderness
Mass
High pitched bowel sounds
Rebound

12. Diagnostic Tests Xray – Free air, perforation CT scan Diverticulum
Thickening
Abscess, fistula
Jacobs DO, N Engl J Med 2007;357:

13. Diagnostic Tests
Colonoscopy and sigmoidoscopy are typically avoided when acute diverticulitis is suspected because of the risk of perforation.
Recommended after approximately 6 weeks, to rule out the presence of other diseases, such as cancer and inflammatory bowel disease.
Jacobs DO, N Engl J Med 2007;357:

14. Treatment of Uncomplicated Acute Diverticulitis
Antibiotics
Jacobs DO, N Engl J Med 2007;357:

15. Treatment of Uncomplicated Acute Diverticulitis
Hospitalization
Inability to tolerate oral medications and liquids
Comorbidities
Pain severe enough to require narcotic analgesia
Symptoms fail to improve despite adequate outpatient therapy
Complicated diverticulitis

16. Complicated Diverticulitis
Abscess
Peritonitis
Obstruction
Fistula formation
Hemorrhage

17. Treatment of Complicated Diverticulitis
IV antibiotics
Bowel rest
Analgesia
Percutaneous drainage (CT-guided)
Surgery

18. Recurrent Diverticulitis
25% will have more than one attack of acute diverticulitis
Parks et al 1969
Recurrence was more virulent and lead to recommendation for elective resection after the second episode in >50year old and after first episode in younger patients.
More recent data fails to show worse prognosis in recurrent attacks.
American Society of Colon and Rectal Surgeons:
Decision for elective resection is on a case by case basis
American Society of Colon and Rectal Surgeons
Sheth et al Am J Gastroenterol 2008; 103: 1550

19. Diverticular Hemorrhage
Rupture of the vasa recta at the dome of a diverticulum
Stone C.

20. Diverticular Hemorrhage
Source proximal to the splenic flexure in 60%
Mean age 66 year old
Most common cause of life threatening lower GI bleed (3-5% of those with diverticulosis)

21. Diverticular Hemorrhage Diagnosis
History and Physical Exam
Painless, sometimes mild cramps
Hematochezia (red blood per rectum)
Radionucleotide Imaging
Technetium sulfur colloid. Scans are obtained shortly after intravenous injection, looking for evidence of extravasation. 0.1 mL/min
Sensitivity 97%, specificity 83%, and positive predictive value 94%

22. Diverticular Hemorrhage Diagnosis
Colonoscopy
Polyethylene glycol for colon purge preparation
Sedation
May be therapeutic

23. Diverticular Hemorrhage Diagnosis
Angiography
Performed by Interventional Radiologist
Bleeding at a rate on 0.5 – 1mL / min
May be therapeutic

24. Therapy for Diverticular Hemorrhage
Spontaneous resolution in 90%
Colonoscopy: Study found 0% versus 53% rebleeding in colonoscopy vs. medical treatment
Epinepherine
Cautery
Clips
Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82
Browder W. Ann Surg 1986 Nov;204(5):530-6

25. Therapy for Diverticular Hemorrhage
Angiography
No purge required
Vasopressin infusion
91% stop bleeding, but 50% rebleed on cessation of vasopressin
Transcatheter embolization is more definitive, but is associated with a up to 20% risk of intestinal infarction.
Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82
Browder W. Ann Surg 1986 Nov;204(5):530-6

26. Surgery for Diverticular Hemorrhage
Frequency of surgery among patients with severe or massive rectal bleeding from 24 to 78%.
18 – 25% of those requiring transfusions
Persistent instability despite aggressive resuscitation demands operative intervention and is necessary
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

27. Surgery for Diverticular Hemorrhage
Surgical mortality is approximately 10%
Exploratory laparotomy identifies a source in 78 percent of patients without a preoperative diagnosis
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

28. Surgery for Diverticular Hemorrhage
Segmental colectomy
Source of bleeding has been localized
Rebleeding in 0 to 14%
Subtotal colectomy
Patient continues to bleed without an identified site of bleeding
Morbidity 37%
Mortality rates 11 – 33%
Blind segmental resection is contraindicated
Rebleeding rate 42%
Morbidity 83%
Mortality 57 %
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

29. Recurrence of Diverticular Hemorrhage
1 year 9%
2 year 10%
3 year 19%
4 year 25%
Longstreth. Am J Gastroenterol 1997; 92: 419

30. Hemorrhoids
Bleday R. Treatment of hemorrhoids. Uptodate.com

31. Hemorrhoids
Arise from a plexus of dilated veins arising from the superior and inferior hemorrhoidal veins.
Submucosal layer in the lower rectum
External or internal: below or above the dentate line.

32. Classification
Grade I: May bulge into the lumen but do not extend below the dentate line.
Grade II: Prolapse out of the anal canal with defecation or with straining but reduce spontaneously.
Grade III: Prolapse out of the anal canal with defecation or straining, and require the patient to reduce them into their normal position.
Grade IV: Irreducible and may strangulate.

33. Bleeding Painless bleeding usually associated with a bowel movement.
Bright red blood coats the stool at the end of defecation.
Blood may drip into the toilet or stain toilet paper.
Chronic blood losses from hemorrhages can be substantial enough to induce iron deficiency anemia.
Bleeding should be investigated:
Flexible sigmoidoscopy or anoscopy in low-risk younger patients
Colonoscopy
Pain should prompt looking for another source

34. Pruritus Irritation or itching of perianal skin
Some patients also complain of mild incontinence or wetness.

35. Pain
Thrombosis, which can occur in both internal and external hemorrhoids. Thrombosis of external hemorrhoids may be associated with excruciating pain.
Easily visible, purple, elliptical mass extending from the anal to the perianal skin.
Thrombosed internal hemorrhoids may also cause pain, but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids strangulate

36. Therapy: American Society of Colon and Rectal Surgeons (ASCRS) Guidelines
Conservative (not generally effective in Grades III, IV)
Fiber
Meta-analysis of seven controlled trials found a significant and consistent benefit from fiber supplementation in improving bleeding (RR 0.50, 95% CI )
Also potentially useful:
Sitz baths
help to relieve irritation and pruritus. In warm water two to three times per day.
Topicals
Steroids
Alonso-Coello P, et al. Cochrane Database Syst Rev 2005;(4):CD

37. Therapy Minimally invasive Mostly for Internal Grades I, II, III.
Band ligation
Coagulation
Sclerotherapy
Cryotherapy

38. Therapy Surgery For refractory to above Thrombosed external
Complications following a standard closed hemorrhoidectomy include urinary retention, urinary tract infection, fecal impaction, delayed hemorrhage, and pain

39. Therapy In patients with thrombosed external hemorrhoids
Either observation or excision. Excision within 48 to 72 hours of the onset of symptoms will result in the most rapid relief of symptoms.

40. Summary Diverticular Disease
Diverticulosis is common and usually asymptomatic.
Symptoms range from mild cramping and bowel movement changes to life threatening infection or hemorrhage
Diverticulitis is an infection of an diverticulum
Uncomplicated cases can be treatment with outpatient oral antibiotics
Severe or complicated cases may require hospitalization and invasive therapeutic modalities

41. Summary Diverticular Bleeding
Is a common cause of massive lower GI hemorrhage
Colonoscopy and angiography may be diagnostic and therapeutic
Surgery is reserved for uncontrolled or refractory cases with best outcomes when the site of bleeding has been localized

42. Summary
Hemorrhoids are common and can cause bleeding, itching, or pain (with thrombosis)
Mild cases can be treated with fiber supplements and topical medications.
Minimally invasive (endoscopic) techniques are available.
Surgery is reserved for severe cases or thrombosis

43. Questions?