51437171-diverticulitis.ppt
TRANSCRIPT
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Diverticular Disease
H.K. Oh M.D.Department of General Surgery
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OverviewA diverticulumdiverticulum is an abnormal sac or pouch protrudin
g from the wall of a hollow organ.• Diverticula ; pouches• Diverticulosis ; condition of having diverticula
DiverticulosisDiverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution.• Decreased consumption of unprocessed cereals along wit
h the increased consumption of sugar and meat The formation of diverticula is also related to aging
• Rare in individuals younger than the age of 30 years, but at least two thirds of Americans will have developed colonic diverticula by the age of 80.
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Pathogenesis Diverticula are actually herniations of m
ucosa through the colon at sites of penetration of the muscular wall by arterioles• On the mesenteric side of the antimesenteri
c teniae Sigmoid colon
• The most common site (50%)• The smallest luminal diameter.• Low fiber diet
-> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall
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Diverticular bleedingThe most common cause of hematochezia in patient
s over the age of 60• 20% of patients with diverticulosis will have GI bleeding.
Risk factor ; HT, Artherosclerosis, NSAIDUsually self limited, but rebleeding risk (25%)Localization ; Colonoscopy, AngiographySurgery
• Unstable hemodynamics, 6-unit bleed within 24 hr• Without localization ; Total colectomy
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DiverticulitisDefinition
• Inflammation of a diverticulum, is related to the retention of particulate material within the diverticular sac and the formation of a fecalith
• Actually an extraluminal pericolic infection caused by the extravasation of feces through the perforated diverticulum
Presentation• LLQ pain : may radiate to the suprapubic, groin, b
ack• Bowel habit change, Anorexia, Fever, Chill, Urinary
urgency
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DiverticulitisPhysical Findings
• Dependent on the site of perforation, the amount of contamination, and the presence or absence of secondary infection of adjacent organs
• Tenderness, Muscle guarding• Tender mass : phlegmon or abscess• Abdominal distension : ileus or obstruction• Tender fluctuant pelvic mass on rectal or vaginal e
xam
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DiverticulitisDiagnostic Tests
• CT The preferred test to confirm the suspected diagnosis Location of infection, extent of inflammatory process, p
resence and location of an abscess, secondary complications
sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ± the collection of contrast material or fluid
• MRI, US• Water soluble contrast enema
Distinguish acute diverticulitis from perforated cancer Risk of increasing the colonic pressure, extravasation o
f feces through the perforated diverticulitis
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Uncomplicated DiverticulitisDisease not associated with free intraperitoneal perf
oration, fistula formation, or obstructionNonoperative treatment
• Bowel rest + Antibiotics ; 75% response• Trimethoprim/sulfamethoxazole or ciprofloxacin and metro
nidazole ; aerobic gram-negative rods and anaerobic bacteria
• The addition of ampicillin to this regimen for nonresponders ; enterococci
• Single-agent therapy ; a third-generation penicillin such as piperacillin
• The usual course of antibiotics is 7 to 10 days
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Uncomplicated DiverticulitisInvestigative studies
• After the symptoms have subsided for at least 3 weeks• To establish the presence of diverticula and to exclude ca
ncer, which can mimic diverticulitis• Colonoscopy > Barium enema
Recurrent disease• Second attack (<25%) -> Third attack (>50%)• Elective resection
After infection control ; usually 4 to 6 weeks after the episode Laparoscopic resection ; growing trend Immunocompromised patient : after single attack
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Complicated DiverticulitisHinchey classification
• Stage I: Pericolic or mesenteric abscess
• Stage II: Walled-off pelvic abscess
• Stage III: Generalized purulent peritonitis
• Stage IV: Generalized fecal peritonitis
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Complicated Diverticulitis Abscess
Usually confined to the pelvis Significant pain, fever, and le
ukocytosis More than 2cm ; should be d
rained• Percutaneous or transanal > la
parotomy Elective surgery ; after 6week
s following drainage• Complete removal of the entire
abnormally thickened bowel
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Complicated DiverticulitisFistula
Skin, bladder, vagina, or small bowel Sigmoid-vesical fistula
• Pneumaturia, fecaluria, and recurrent UTI (Urosepsis)
• CT ; may demonstrate air in the bladder
• Barium enema, IVP, CystoscopyTreatment
• Initial treatment ; infection control and reduce the associated inflammation• Rarely a cause for emergency surgery
• Diagnostic steps such as coloscopy should be taken to confirm the cause of the fistula before a definitive operation is undertaken.
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Generalized Peritonitis Mechanism
• Perforation without sealing by the body’s normal defenses -> contaminated with feces
• Abscess burst into the unprotected peritoneal cavity -> contaminated with enteric bacteria
Immediate operative intervention• Excise the segment of colon containing perforation and c
onstruct a colostomy using noninflammed colon• Peritoneal cavity irrigation, iv antibiotics
Colostomy repair• Usually after a period of at least 10 weeks
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Diverticulosis in KoreaCharacteristics
• Low incidence, but increasing• Rt colon (over 60%) > Lt colon • Young Age, Man, Congenital, Solitary, True type, Uncompli
cated typeDifferential Diagnosis from Acute Appendicitis
• RLQ pain ; first symptom site, long duration• Nausea, vomiting ; absent or low• Previous appendectomy• Known diverticulosis (Barium enema, Colonoscopy)• Fecalith • Age ; 30~40 year old (later than appendicitis)• History of lower GI bleeding
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References Sabiston Textbook of Surgery 17ed Harrison’s Principles of Internal Medicine 16th Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current mana
gement of diverticulitis. Curr Surg. 2004 Jul-Aug;61(4):361-5 Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of el
ective colectomy in diverticulitis: a decision analysis. J Am Coll Surg. 2004 Dec;199(6):904-12.
Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate? Surgery. 2004 Oct;136(4):725-30.
Park JK et al. Clinical analysis of right colon diverticulitis. J Korean Surg Soc 2003 Jan;64:44-48
Chang JH et al. Surgical treatment of the colonic diverticulosis. J Korean Surg Soc 2002 May;62:415-420
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Thank you for your attentions.