1. Colonic Diverticulosis: A review Dr. Matt W. Johnson BSc MBBS MRCP MD Consultant Gastroenterologist

2. Diverticulosis

3. Operative Picture

4. Introduction Diverticular ? disease (or Variant of normal ?) Diverticular ? disease (or Variant of normal ?) Prevalence = 40% in those >50y Prevalence = 40% in those >50y 70% of those >80y 70% of those >80y 68,000 Hospital admissions / year in UK 68,000 Hospital admissions / year in UK 2,000 deaths / year in UK 2,000 deaths / year in UK Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial number NCT00663247. 2010 Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial number NCT00663247. 2010 Diverticular disease and diverticulitis, Clinical Knowledge Summaries (March 2008) Diverticular disease and diverticulitis, Clinical Knowledge Summaries (March 2008) Diverticular disease and diverticulitis, Diverticular disease and diverticulitis,

5. Diverticulosis Demand on L&D Services 70-80% of new patient clinic appointments are for ABHs 70-80% of new patient clinic appointments are for ABHs Over the last 7y = 12,000 FS’s Over the last 7y = 12,000 FS’s Of these;- Of these;- –5,500 = Normal 47% –500 = Haemorrhoids<5% –2,000 = Diverticulosis17% –580 = Colitis5% –500 = Rectal Cancer and Polyps<5%

6. Introduction BSG recommendation re - terminology Diverticulosis - Asymptomatic (75%) Diverticulosis - Asymptomatic (75%) Diverticular disease- Symptomatic (<25%) Diverticular disease- Symptomatic (<25%) Diverticulitis- Inflamed/Infected (75%) Diverticulitis- Inflamed/Infected (75%) Diverticular colitis- Associated colitis Diverticular colitis- Associated colitis Diverticular bleeding- 15% Diverticular bleeding- 15%

7. Introduction & Overview Epidemiology Epidemiology Pathophysiology Pathophysiology Diverticulosis Diverticulosis Complications Complications –Symptomatic DD –Diverticulitis –Diverticular colitis –Diverticular haemorrhage –Stricture obstruction –Fistula Management Management

8. Cross Sectional Bowel Anatomy

9. Cross Section of Diverticulae

10. Physiology and Anatomy Terminal arterial branches Penetrate circular muscle Often lie adjacent to taenia

11. Physiology High intra-luminal pressure gradient High intra-luminal pressure gradient Weakest at the point where the terminal arterial branches penetrate through the circular muscles. Weakest at the point where the terminal arterial branches penetrate through the circular muscles. Rectal sparing Rectal sparing –?due to complete layer of longitudinal muscle and large diameter

12. Pathology Congenital Congenital Acquired - Multifactorial Acquired - Multifactorial –Mychosis Increased depositioning of collagen + elastin in taeniae = shortening and thickening = narrowing with increased luminal pressures Increased depositioning of collagen + elastin in taeniae = shortening and thickening = narrowing with increased luminal pressures –Hypersegmentation Non-propulsive contraction of circular muscle in closed segment = increases luminal pressure = herniation Non-propulsive contraction of circular muscle in closed segment = increases luminal pressure = herniation –Laplace’s Law Transmural P gradient = Wall tension ÷ radius = Sigmoid Transmural P gradient = Wall tension ÷ radius = Sigmoid –Structural wall abnormalities Ehlers Danlos, Marfan’s, PCKD - Reduced tensile strength of CT Ehlers Danlos, Marfan’s, PCKD - Reduced tensile strength of CT –Dietary factors 1+2+3 West (insoluble fibre) > East (soluble fibre) rare in Africa West (insoluble fibre) > East (soluble fibre) rare in Africa Insoluble stool fibre = increases stool bulk = larger colon diameter = impaired segmental contractions = higher intra-luminal pressures Insoluble stool fibre = increases stool bulk = larger colon diameter = impaired segmental contractions = higher intra-luminal pressures 1 Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005

13. Idiopathic Slow Transit Constipation Day 5 after taking markers

14. Diverticulosis 75% = most found incidentally 75% = most found incidentally When questioned most will have symptoms ie = Diverticular disease When questioned most will have symptoms ie = Diverticular disease No proven evidence that Mx helps prevent enlargement or further development of diverticulae No proven evidence that Mx helps prevent enlargement or further development of diverticulae

15. Epidemiology - Location Classically Sigmoid Classically Sigmoid In Orient often right-sided In Orient often right-sided Rectal Sparing Rectal Sparing Can occur anywhere e.g. Small bowel Can occur anywhere e.g. Small bowel

16. Diverticulosis Right SidedLeft Sided

17. Diverticular Disease Altered bowel habits (pellets / loose) Altered bowel habits (pellets / loose) Bloating / Flatulence / Borborygmi Bloating / Flatulence / Borborygmi Incomplete evacuation Incomplete evacuation LIF discomfort relieved by defaecation LIF discomfort relieved by defaecation Mx = Soften and shift stool Mx = Soften and shift stool –High fluid >2L/d –Low residue (high soluble fibre) diet –+/- Movicol 1 sachet bd –+/- Mesalazines –+/- Buscopan / Spasmolol / Colperamin / Mebeverine –Avoid opioids + Loperamide

19. Diverticulitis Cause Cause –Inspissation of faecal content stuck in diverticlum –Obstruction of the diverticulum –Increased pressure = local ischaemia + breakdown of mucosal barrier –Localise bacterial overgrowth + translocation across membrane = micro-abscesses

20. S+S’s of Diverticulitis Symptoms LIF pain (can be right sided) LIF pain (can be right sided) ABH / Diarrhoea ABH / Diarrhoea N+V N+VSigns Pyrexia (Temp > 38°C) Pyrexia (Temp > 38°C) Wbc(>12) Wbc(>12) ESR or CRP ESR or CRP CXR + AXR CXR + AXR US < CT scan(exclude complications eg. abscess) US < CT scan(exclude complications eg. abscess)

21. Management Ix Bloods Bloods Rectal examination (avoid sigmoidoscopy for 2 weeks) Rectal examination (avoid sigmoidoscopy for 2 weeks) CXR CXR AXR AXR USS or CT Scan USS or CT ScanMx Resuscitation IV fluids Resuscitation IV fluids Antibiotics Antibiotics Analgesia Analgesia Operative intervention Operative intervention

22. Hinchney Classification of Diverticulitis GradeExtentMortalityPrognosis 1 Localised abscess <5% 2 Abscess into pelvis 5% 3 Purulent peritonitis 13% 4 Faeculant peritonitis 43% Hinchney EJ. AdvSurg.1978;12:85-109

23. Acute Diverticulitis Abscess Abscess –Peridiverticular –Mesenteric –Pericolic Perforation Perforation –Concealed –Free Peritonitis (gangrenous sigmoidits) Peritonitis (gangrenous sigmoidits) –Purulent or serous or faecal –Local or generalised or pelvic 1 Killingback Surg Clin North Am 1983

24. Diverticulitis with pericolic abscess

25. Management of Complicated Diverticulitis Mild / Grade 1 Mx = Outpatient, High fluid + low residue diet Mx = Outpatient, High fluid + low residue diet Rx = OP ABs 7-10d Rx = OP ABs 7-10d (Metronidazole + Co-amoxiclav or Ciprofloxacin) (Metronidazole + Co-amoxiclav or Ciprofloxacin) Moderate / Grade 2 Moderate / Grade 2 Mx = In-patient, As above Mx = In-patient, As above Rx = IV Abs +/- XR guided drainage Rx = IV Abs +/- XR guided drainage Severe / Grade 3+4 or with Complications Severe / Grade 3+4 or with Complications Mx = IP Resuscitation, As above Mx = IP Resuscitation, As above Rx= IV ABs + Contact Surgeons Rx= IV ABs + Contact Surgeons

26. Elective resection for Diverticulitis Emergency surgery for perforated Diverticulosis with peritonitis = Mortality rate of 7% 1 Emergency surgery for perforated Diverticulosis with peritonitis = Mortality rate of 7% 1 Diverticular Surgery = High complication rate 2 Diverticular Surgery = High complication rate 2 For emergency surgery = Primary anastomosis For emergency surgery = Primary anastomosis –A RMCCT found one-stage procedure (primary anastomosis) significantly reduced rates of postoperative peritonitis and emergency re-operation compared with a two-stage procedure (formation of an end colostomy with oversewing of the rectal stump - Hartmann's procedure) 3 25% of patients have ongoing symptoms after bowel resection (IBS/IBD) 3 25% of patients have ongoing symptoms after bowel resection (IBS/IBD) 3 No evidence to support elective prophylactic surgery No evidence to support elective prophylactic surgery Schilling et al. 2001 Diseases of the Colon and Rectum 1 Schilling et al. 2001 Diseases of the Colon and Rectum 2 2 Krukowski & Matheson Br J Surg 1984 3 Janes SE, Meagher A, Frizelle FA; Management of diverticulitis. BMJ. 2006 Feb 4;332(7536):271-5 Janes SE, Meagher A, Frizelle FA

27. Diverticular colitis Presentations Presentations –Asymptomatic –Bloody diarrhoea –Abdo pain Affects sigmoid like UC but doesn’t effect rectum Affects sigmoid like UC but doesn’t effect rectum Rx = Mesalazines 1,2,3,4 Rx = Mesalazines 1,2,3,4 1 Spiller RC. NCI00663247 2 Mario F. JClinGastro. 2006;40Suppl3:S1. 55-9 3 G. Did Dis Sci. 2007;52:2934-41 4 A. Dig Dis Sci. 2007. 2007;52:671-4

28. Complications of Diverticulitis Bleeding 1 (15-25%) Bleeding 1 (15-25%) Perforation (25%) Perforation (25%) Obstruction Obstruction Fistulae Fistulae Abscess Abscess May co-exist with IBD May co-exist with IBD Specimen showing blood in diverticulae 1 Travis S. Colonic Diverticular Disease 2005;312

29. Bleeding in Diverticular Disease 3-5% of all diverticulosis3-5% of all diverticulosis 15-25% of all the diverticulitis 115-25% of all the diverticulitis 1 Accounts for 40% of all LGI bleeding 1Accounts for 40% of all LGI bleeding 1 75-90% stop spontaneously 275-90% stop spontaneously 2 10-40% risk of re-bleed 210-40% risk of re-bleed 2 Morbidity + Mortality rate = 10-20% 3Morbidity + Mortality rate = 10-20% 3 1 Gostout CJ. JClinGastro. 1992;14(3):260 2 McGuire HH Jr. Ann Surg. 1994;220(5):653 3 Uden P. Dis Colon Rectum. 1986;29(9):561

30. Management of Diverticular Bleeds Mx Resuscitation + TransfusionResuscitation + Transfusion Rbc labelling scan (0.1ml/m)Rbc labelling scan (0.1ml/m) Localisation = 24-91% Localisation = 24-91% Mesenteric angiography (0.5ml/m)Mesenteric angiography (0.5ml/m) +/- Embolism +/- Embolism Endoscopic therapiesEndoscopic therapies Adrenaline +/- Endoclips Adrenaline +/- Endoclips Sx targeted resectionSx targeted resection

31. Re-Bleeding Rates Re-bleeding rate 1 Longstreth Am J Gastro 1997 YearPercentage 19 210 319 425

32. Other Causes Of Colonic Bleeding ExcludeExclude – IBD – Neoplasm – Angiodysplasia – Ischaemic colitis – Radiation proctitis – Varices

33. Perforation (35% Mortality)

34. CT Scan Perforated diverticulitis of the sigmoid colon-CT

35. CXR

36. AXR

37. Obstruction in Diverticular Disease Increased fibrotic reaction leads to stricturing Increased fibrotic reaction leads to stricturing Often present like cancer Often present like cancer Progressive distension with faecal loading Progressive distension with faecal loading Single contrast enema will delineate this Single contrast enema will delineate this Diagnosis Diagnosis –often only at operation (opened specimen) or –on histology

38. Fistula Abnormal connections Abnormal connections Colovaginal (esp if prev TAH) Colovaginal (esp if prev TAH) Colovesical Colovesical –Pneumaturia –Recurrent infections –Faecalent urine or particulates

39. Duodenal and Jejunal Diverticulosis Different to colonic diverticulosis. Different to colonic diverticulosis. Most occur in jejunum and (occasionally) duodenum. Most occur in jejunum and (occasionally) duodenum. Commonly associated with bacterial overgrowth. Commonly associated with bacterial overgrowth. Jejunal diverticula are acquired secondary to protrusions of the mucosal lining through the muscular wall of the bowel. Jejunal diverticula are acquired secondary to protrusions of the mucosal lining through the muscular wall of the bowel. Vitamin deficiencies Vitamin deficiencies –Increased colonic transit = Reduced Vit D (+Ca) + Iron –SBBO = Reduced B12+ Increased Folate Patients may present with anaemia and osteomalacia. Patients may present with anaemia and osteomalacia.

40. Proximal Jejunal Diverticulitis

41. Incidental Jejunal Diverticular

42. Proximal Jejunal diverticulitis with perforation

43. Further Reading COLONIC DIVERTICULOSIS: A REVIEW COLONIC DIVERTICULOSIS: A REVIEW Tyara Banerjee, Tyara Banerjee, Suman Verma, Suman Verma, Matthew W. Johnson. Matthew W. Johnson. Good Clinical Care Good Clinical Care

44. Graham Holland’s Luton ‘the optimism and the frustration of living in a metropolis’