1. COLONIC DIVERTICULAR DISEASE

2. INCIDENCE & EPIDEMIOLOGY

3. ½ of individuals >60y/o 20% of patients develop symptomatic disease
Western population
½ of individuals >60y/o
20% of patients develop symptomatic disease
United States
>200,000 hospitalization annually
5th most costly GI disorder
Mean hospital stay: 9.7 days
Average cost: $42,000/patient
Mean age at presentation: 59 years
F=M, men present at younger age

4. Rare, diets include more fiber and rough-age
Underdeveloped countries
Rare, diets include more fiber and rough-age
However, shortly following migration in the U.S., immigrants will develop diverticular disease at the same rate as U.S. natives
Philippines
Extrapolated prevalence: 634,130 out of 86,241,697 (population estimated)*
Extrapolated incidence: 95,119 out of 86,241,697 (population estimated)*
* US Census Bureau, International Data Base, 2004 ( the extrapolations for Diverticular Disease are only estimates and may have limited relevance to the actual incidence of Diverticular Disease in any region)

5. TYPES OF COLONIC DIVERTICULAR DISEASE

6. TYPES TRUE DIVERTICULA FALSE DIVERTICULA
involves only protrusion of the mucosa through the muscularis propria of the colon
most common
TRUE DIVERTICULA
a saclike herniation of the entire bowel wall

7. PATHOPHYSIOLOGY

9. PATHOPHYSIOLOGY
Protrusion occurs at the point where the NUTRIENT ARTERY or VASA RECTI penetrates through the muscularis propria
Break in the integrity of the colonic wall
Compression or erosion
PERFORATION BLEEDING

10. PATHOPHYSIOLOGY commonly affect the SIGMOID COLON due to:
Relative high pressure zone within the muscular sigmoid colin.
Higher amplitude contractions combined with constipated, high fat content stool within the sigmoid lumen results in the creation of these diverticula
Related to retention of particulate material within the diverticular sac and formation of fecalith

11. Diverticular bleeding
Presentation, Evaluation, and Management

12. Diverticular Bleeding
Hemorrhage from a colonic diverticulum is the most common cause of hematochezia in patients >60 years.
Only 20% of patients with diverticulosis will have GI bleeding.
Most bleeds are self-limited and stop spontaneously with bowel rest.
Lifetime risk of rebleeding: 25%
At Increased Risk For Bleeding
Hypertension
(+)
(+) Atherosclerosis
Regular NSAID use

13. Diverticular Bleeding
Colonoscopy
To localize the bleeding
May be both diagnostic and therapeutic in the management of mild to moderate diverticular bleeding
Angiography
Management of massive bleeding in a stable patient
Mesenteric angiography can localize the bleeding site and occlude the bleeding vessel successfully with a coil in 80% of the cases
Follow up: Repetitive colonoscopy to look for evidence of colonic ischemia
Segmental resection of the colon
To eliminate risk of further bleeding
In patients on chronic blood thinners

14. Diverticular Bleeding
Highly selective coil embolization
Rate of colonic ischemia: <10%
Risk of acute rebleeding: <25%
Selective infusion of vasopressin
To stop hemorrhage
Complications: MI, intestinal ischemia
Recurrence of bleeding in 50% of patients once infusion is stopped

15. Diverticular Bleeding
Surgery
Indications: if patient is unstable or has had a 6-unit bleed within 24 h
Total abdominal colectomy
Patients with presumed bleeding from diverticular disease requiring emergent surgery without localization
Rationale: Colonic diverticulosis is more often seen from the R colon
Surgical resection with primary anastomosis
In patients without severe comorbidities
A higher anastomotic leak rate has been reported in patients who received >10 units of blood

16. Diverticulitis
Presentation, Evaluation, and Management

17. DIVERTICULITIS Uncomplicated – 75% Complicated – 25% Abdominal Pain
Fever
Leukocytosis
Anorexia/obstipation
Complicated – 25%
Abscess 16%
Perforation 10%
Stricture 5%
Fistula 2%
Presentation of Diverticular Disease

18. Diverticulitis Diverticular perforation
Generalized peritonitis in <25% of cases
(+) Abdominal distention
Giant diverticulum of the sigmoid
(+) Air fluid level in the LLQ on plain abdominal film
Mx: resection to avoid impending perforation

19. Diverticulitis Diagnosis is best made on CT. CT Scan Findings
Sigmoid diverticula
Thickened colonic wall >4mm
Inflammation within the pericolic fat ± collection of contrast material or fluid

20. Diverticulitis
Suspected diverticulitis that does not meet CT criteria or is not associated with a leukocytosis or fever is not diverticular disease
Conditions that mimic diverticular disease:
IBS
Ovarian cyst
Endometriosis
Acute appendicitis
PID

21. Diverticulitis Barium enema or colonoscopy
Should be performed ~6 weeks after an attack of diverticular disease
A sigmoid malignancy can masquerade as diverticular disease.
Should not be performed in the acute setting
Higher risk of colonic perforation associated with insufflation or insertion of barium-based contrast material under pressure.

22. Diverticulitis Complicated diverticular disease
Diverticular disease associated with an abscess or perforation, and less commonly with a fistula.
With fistula formation
Common locations include cutaneous, vaginal or vesicle fistulae
Present with either passage of stool through skin or vagina, or pneumaturia
Colovaginal fistulae: more common in women who have undergone hysterectomy
Pneumaturia – presence of air in the urinary stream

23. Hinchey Classification of Perforated Diverticular Disease
Stage I: perforated diverticulitis with a confined paracolic abscess
Stage II: perforated diverticulitis that has closed spontaneously with distant abscess formation
Stage III: noncommunicating perforated diverticulitis with fecal peritonitis (the diverticular neck is closed off and therefore contrast will not freely expel on radiographic images)
Stage IV: perforation and free communication with the peritoneum, resulting in fecal peritonitis

24. Medical Management of Diverticular Disease
Asymptomatic
Diet alterations – fiber-enriched diet, including 30g of fiber/day
Supplementary fiber products: Metamucil, Fibercon, Citrucel
Avoid nuts and popcorn – may obstruct the lumen of the diverticulum
Asymptomatic – discovered only on imaging studies or at the time of colonoscopy

25. Medical Management of Diverticular Disease
Symptomatic
Radiographic and hematologic confirmation of inflammation and infection within the colon
Treated initially with antibiotics and bowel rest
TMP-SMX or ciprofloxacin and metronidazole
(+) Ampicillin – for nonresponders
Alternative: IV piperacillin or oral penicillin/clavulinic acid
Usual course: 7-10 days
Rifixamin + fiber – less frequent recurrent symptoms from uncomplicated diverticular disease
Limited diet until pain resolves
Medical therapy can be continued beyond 2 attacks without an increased risk of perforation requiring a colostomy, especially in those >50 years.
Asymptomatic – discovered only on imaging studies or at the time of colonoscopy
TMP-SMX or cipro + metro – target aerobic gram – rods and anaerobic bacteria; do not cover enterococci, so ampicillin is added to regimen for nonresponsders

26. Surgical Management of Diverticular Disease
In patients who are low risk (ASA I and II) who have had at least 2 documented attacks requiring hospitalization or those who do not rapidly improve on medical therapy
Younger patients – more aggressive form of disease
Waiting beyond two attacks is not recommended.
In all low surgical risk patients with complicated diverticular disease

27. Surgical Management of Diverticular Disease
Goals of Surgical Management
Control sepsis
Eliminate complications such as fistula or obstruction
Remove diseased colonic segment
Restore intestinal continuity

28. Surgical Management of Diverticular Disease

29. Surgical Management of Diverticular Disease
Open or laparoscopic sigmoid resection – current option of uncomplicated diverticular disease
Benefits of laparoscopic over open resection:
Early discharge (by at least 1 day)
Less narcotic use
Earlier return to work
Benefits of open over laparoscopic resection:
Shorter operative procedure
Less costly
Complication rates are similar.

30. Surgical Management of Complicated Diverticular Disease
Proximal diversion of the fecal stream with an ileostomy or colostomy and sutured omental patch with drainage
Resection with colostomy and mucus fistula or closure of distal bowel with formation of a Hartmann’s pouch
Resection with anastomosis (coloproctostomy)
Resection with anastomosis and diversion (coloproctostomy with loop ileostomy or colostomy)

31. Surgical Management of Diverticular Diseases
Hinchey Stages I and II
Percutaneous drainage followed by resection with anastomosis about 6 weeks later
Percutaneous drainage
For abscesses ≥ 5 cm with a well-defined wall that is accessible
If <5cm, may resolve with antibiotics alone
Contraindications to percutaneous drainage:
No percutaneous access route
Pneumoperitoneum
Fecal peritonitis

32. Surgical Management of Diverticular Diseases
Hinchey Stages I and II
If patients develop generalized peritonitis  Hartmann’s procedure
Nonoperative therapy – 20% recurrence rate at 2 years in patients with Hinchey Stage I disease
80% of patients with Hinchey Stage II required surgical resection for recurrent symptoms.

33. Surgical Management of Diverticular Diseases
Hinchey Stage III
Hartman’s procedure or with primary anastomosis and proximal diversion
If patient has significant comorbidities: intraoperative peritoneal lavage (irrigation), omental patch to the oversewn perforation, and proximal diversion of the fecal stream with either an ileostomy or transverse colostomy can be performed
Hinchey Stage IV
No anastomosis of any type should be attempted.

34. Recurrent Symptoms in Diverticular Disease
Occurs in 10% of patients.
Recurrence develops in patients following inadequate surgical resection.
A retained segment of diseased rectosigmoid colon is associated with twice the incidence of recurrence.
IBS – may also cause recurrence of initial symptoms
Patients undergoing surgical resection for presumed diverticulitis and symptoms consistent with IBS have functionally poorer outcomes.