Colonic Diverticulosis: Colonic Diverticulosis: A reviewA review

Dr. Matt W. Johnson Dr. Matt W. Johnson BSc MBBS MRCP MDBSc MBBS MRCP MD

Consultant GastroenterologistConsultant Gastroenterologist

DiverticulosisDiverticulosis

Operative PictureOperative Picture

IntroductionIntroduction

• 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 >80y70% of those >80y

• 68,000 Hospital admissions / year in UK68,000 Hospital admissions / year in UK

• 2,000 deaths / year in UK2,000 deaths / year in UK

• Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Spiller RC. Mechanistic RCT of Mesalazine in Symptomatic Diverticular Disease. Clinical Trial number NCT00663247. 2010Trial number NCT00663247. 2010

• Diverticular Diverticular disease and disease and diverticulitisdiverticulitis,, Clinical Knowledge Summaries (March 2008) Clinical Knowledge Summaries (March 2008)

Diverticulosis Demand on Diverticulosis Demand on L&DL&DServicesServices• 70-80% of new patient clinic appointments 70-80% of new patient clinic appointments

are for ABHsare for ABHs

• Over the last 7y = 12,000 FS’sOver the last 7y = 12,000 FS’s• Of these;- Of these;-

– 5,500 5,500 = Normal = Normal 47%47%– 500 500 = Haemorrhoids= Haemorrhoids <5%<5%– 2,000 2,000 = Diverticulosis= Diverticulosis 17%17%– 580 580 = Colitis= Colitis 5%5%– 500 500 = Rectal Cancer and Polyps= Rectal Cancer and Polyps <5%<5%

IntroductionIntroduction

BSG recommendation re - terminologyBSG recommendation re - terminology

• Diverticulosis Diverticulosis - Asymptomatic (75%)- Asymptomatic (75%)

• Diverticular diseaseDiverticular disease - Symptomatic (<25%)- Symptomatic (<25%)

• DiverticulitisDiverticulitis - Inflamed/Infected - Inflamed/Infected (75%)(75%)

• Diverticular colitisDiverticular colitis - Associated colitis- Associated colitis

• Diverticular bleedingDiverticular bleeding - 15%- 15%

Introduction & OverviewIntroduction & Overview

• EpidemiologyEpidemiology• PathophysiologyPathophysiology• DiverticulosisDiverticulosis• ComplicationsComplications

– Symptomatic DDSymptomatic DD– DiverticulitisDiverticulitis– Diverticular colitisDiverticular colitis– Diverticular haemorrhageDiverticular haemorrhage– Stricture obstructionStricture obstruction– FistulaFistula

• ManagementManagement

Cross Sectional Bowel Cross Sectional Bowel AnatomyAnatomy

Cross Section of Cross Section of DiverticulaeDiverticulae

Physiology and AnatomyPhysiology and Anatomy

•Terminal arterial branches

•Penetrate circular muscle

•Often lie adjacent to taenia

PhysiologyPhysiology

• High intra-luminal pressure gradientHigh intra-luminal pressure gradient

• Weakest at the point where the terminal Weakest at the point where the terminal arterial branches penetrate through the arterial branches penetrate through the circular muscles.circular muscles.

• Rectal sparing Rectal sparing – ?due to complete layer of longitudinal muscle and ?due to complete layer of longitudinal muscle and

large diameterlarge diameter

PathologyPathology• CongenitalCongenital• Acquired - MultifactorialAcquired - Multifactorial

– MychosisMychosis• Increased depositioning of collagen + elastin in taeniae = Increased depositioning of collagen + elastin in taeniae =

shortening and thickening = narrowing with increased luminal shortening and thickening = narrowing with increased luminal pressurespressures

– HypersegmentationHypersegmentation• Non-propulsive contraction of circular muscle in closed segment = Non-propulsive contraction of circular muscle in closed segment =

increases luminal pressure = herniationincreases luminal pressure = herniation– Laplace’s LawLaplace’s Law

• Transmural P gradient = Wall tension ÷ radius = SigmoidTransmural P gradient = Wall tension ÷ radius = Sigmoid– Structural wall abnormalities Structural wall abnormalities

• Ehlers Danlos, Marfan’s, PCKD - Reduced tensile strength of CTEhlers Danlos, Marfan’s, PCKD - Reduced tensile strength of CT– Dietary factors Dietary factors 1+2+31+2+3

• West (insoluble fibre) > East (soluble fibre) rare in AfricaWest (insoluble fibre) > East (soluble fibre) rare in Africa• Insoluble stool fibre = increases stool bulk = larger colon diameter Insoluble stool fibre = increases stool bulk = larger colon diameter

= impaired segmental contractions = higher intra-luminal pressures = 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

Idiopathic Slow Transit Idiopathic Slow Transit ConstipationConstipation

Day 5 after taking markers

DiverticulosisDiverticulosis

• 75% = most found incidentally75% = most found incidentally

• When questioned most will have When questioned most will have symptoms ie = Diverticular diseasesymptoms ie = Diverticular disease

• No proven evidence that Mx helps prevent No proven evidence that Mx helps prevent enlargement or further development of enlargement or further development of diverticulaediverticulae

Epidemiology - LocationEpidemiology - Location

• Classically SigmoidClassically Sigmoid

• In Orient often right-sidedIn Orient often right-sided

• Rectal SparingRectal Sparing

• Can occur anywhereCan occur anywheree.g. Small bowele.g. Small bowel

DiverticulosisDiverticulosis

Right Sided Left Sided

Diverticular DiseaseDiverticular Disease

• Altered bowel habits (pellets / loose)Altered bowel habits (pellets / loose)• Bloating / Flatulence / BorborygmiBloating / Flatulence / Borborygmi• Incomplete evacuationIncomplete evacuation• LIF discomfort relieved by defaecationLIF discomfort relieved by defaecation

• Mx = Soften and shift stoolMx = Soften and shift stool– High fluid >2L/dHigh fluid >2L/d– Low residue (high soluble fibre) dietLow residue (high soluble fibre) diet– +/- Movicol 1 sachet bd+/- Movicol 1 sachet bd– +/- Mesalazines+/- Mesalazines– +/- Buscopan / Spasmolol / Colperamin / Mebeverine+/- Buscopan / Spasmolol / Colperamin / Mebeverine– Avoid opioids + LoperamideAvoid opioids + Loperamide

DiverticulitisDiverticulitis

• CauseCause– Inspissation of faecal content stuck in Inspissation of faecal content stuck in

diverticlumdiverticlum– Obstruction of the diverticulumObstruction of the diverticulum– Increased pressure = local ischaemia + Increased pressure = local ischaemia +

breakdown of mucosal barrierbreakdown of mucosal barrier– Localise bacterial overgrowth + Localise bacterial overgrowth +

translocation across membrane = micro-translocation across membrane = micro-abscesses abscesses

S+S’s of DiverticulitisS+S’s of Diverticulitis

SymptomsSymptoms• LIF pain LIF pain (can be right sided)(can be right sided)• ABH / DiarrhoeaABH / Diarrhoea• N+VN+V

SignsSigns• Pyrexia Pyrexia (Temp > 38°C)(Temp > 38°C)• WbcWbc (>12)(>12)• ESR or CRPESR or CRP• CXR + AXRCXR + AXR• US < CT scanUS < CT scan (exclude complications eg. abscess)(exclude complications eg. abscess)

ManagementManagement

IxIx• BloodsBloods• Rectal examination (avoid sigmoidoscopy for 2 Rectal examination (avoid sigmoidoscopy for 2

weeks)weeks)• CXRCXR• AXRAXR• USS or CT ScanUSS or CT Scan

MxMx• Resuscitation IV fluidsResuscitation IV fluids• AntibioticsAntibiotics• AnalgesiaAnalgesia• Operative interventionOperative intervention

Hinchney Classification of Hinchney Classification of DiverticulitisDiverticulitis

GradeGrade ExtentExtent MortalityMortality

PrognosisPrognosis

11 Localised Localised abscessabscess

<5%<5%

22 Abscess into Abscess into pelvispelvis

5%5%

33 Purulent Purulent peritonitis peritonitis

13%13%

44 Faeculant Faeculant peritonitisperitonitis

43%43%

Hinchney EJ. AdvSurg.1978;12:85-109

Acute DiverticulitisAcute Diverticulitis

• AbscessAbscess– PeridiverticularPeridiverticular– MesentericMesenteric– PericolicPericolic

• PerforationPerforation– ConcealedConcealed– FreeFree

• Peritonitis (gangrenous sigmoidits)Peritonitis (gangrenous sigmoidits)– Purulent or serous or faecalPurulent or serous or faecal– Local or generalised or pelvicLocal or generalised or pelvic

1 Killingback Surg Clin North Am 1983

Diverticulitis Diverticulitis with pericolic abscesswith pericolic abscess

Management of Management of Complicated DiverticulitisComplicated Diverticulitis

Mild / Grade 1Mild / Grade 1• Mx Mx = Outpatient, High fluid + low residue diet = Outpatient, High fluid + low residue diet • Rx Rx = OP ABs 7-10d = OP ABs 7-10d

• (Metronidazole + Co-amoxiclav or Ciprofloxacin)(Metronidazole + Co-amoxiclav or Ciprofloxacin)

• Moderate / Grade 2Moderate / Grade 2• Mx Mx = In-patient, As above= In-patient, As above• Rx Rx = IV Abs +/- XR guided drainage = IV Abs +/- XR guided drainage

• Severe / Grade 3+4 or with ComplicationsSevere / Grade 3+4 or with Complications• Mx Mx = IP Resuscitation, As above= IP Resuscitation, As above• RxRx = IV ABs + Contact Surgeons= IV ABs + Contact Surgeons

Elective resection for Elective resection for DiverticulitisDiverticulitis• Emergency surgery for perforated Diverticulosis with Emergency surgery for perforated Diverticulosis with

peritonitis = Mortality rate of 7% peritonitis = Mortality rate of 7% 11

• Diverticular Surgery = High complication rate Diverticular Surgery = High complication rate 22 • For emergency surgery = Primary anastomosisFor emergency surgery = Primary anastomosis

– A RMCCT found one-stage procedure (primary anastomosis) A RMCCT found one-stage procedure (primary anastomosis) significantly reduced rates of postoperative peritonitis and significantly reduced rates of postoperative peritonitis and emergency re-operation compared with a two-stage procedure emergency re-operation compared with a two-stage procedure (formation of an end colostomy with oversewing of the rectal (formation of an end colostomy with oversewing of the rectal stump - Hartmann's procedure) stump - Hartmann's procedure) 33

• 25% of patients have ongoing symptoms after bowel 25% of patients have ongoing symptoms after bowel resection (IBS/IBD) resection (IBS/IBD) 33

• No evidence to support elective prophylactic surgeryNo evidence to support elective prophylactic surgery

1 Schilling et al. 2001 Diseases of the Colon and RectumSchilling et al. 2001 Diseases of the Colon and Rectum

22 Krukowski & Matheson Br J Surg 1984

3 Janes SE, Meagher A, Frizelle FA; Management of diverticulitis. BMJ. 2006 Feb 4;332(7536):271-5

Diverticular colitisDiverticular colitis

• PresentationsPresentations– AsymptomaticAsymptomatic– Bloody diarrhoea Bloody diarrhoea – Abdo painAbdo pain

• Affects sigmoid like UC but doesn’t effect Affects sigmoid like UC but doesn’t effect rectumrectum

• Rx = Mesalazines Rx = Mesalazines 1,2,3,41,2,3,4

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

Complications of Complications of DiverticulitisDiverticulitis

• BleedingBleeding11 (15-25%) (15-25%)

• PerforationPerforation (25%) (25%)

• Obstruction Obstruction

• FistulaeFistulae

• AbscessAbscess

• May co-exist with IBDMay co-exist with IBD Specimen showing blood in diverticulae

1 Travis S. Colonic Diverticular Disease 2005;312

Bleeding in Diverticular Bleeding in Diverticular DiseaseDisease

• 3-5% of all diverticulosis3-5% of all diverticulosis• 15-25% of all the diverticulitis 15-25% of all the diverticulitis 11

• Accounts for 40% of all LGI bleeding Accounts for 40% of all LGI bleeding 11

• 75-90% stop spontaneously 75-90% stop spontaneously 22

• 10-40% risk of re-bleed 10-40% risk of re-bleed 22

• Morbidity + Mortality rate = 10-20% Morbidity + Mortality rate = 10-20% 33

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

Management of Diverticular Management of Diverticular BleedsBleeds

MxMx• Resuscitation + TransfusionResuscitation + Transfusion• Rbc labelling scan Rbc labelling scan (0.1ml/m)(0.1ml/m)

•Localisation = 24-91%Localisation = 24-91%

• Mesenteric angiography Mesenteric angiography (0.5ml/m) (0.5ml/m) •+/- Embolism+/- Embolism

• Endoscopic therapies Endoscopic therapies •Adrenaline +/- EndoclipsAdrenaline +/- Endoclips

• Sx targeted resectionSx targeted resection

Re-Bleeding RatesRe-Bleeding Rates

Re-bleeding rateRe-bleeding rate

1 Longstreth Am J Gastro 1997

YearYear PercentagePercentage

11 99

22 1010

33 1919

44 2525

Other Causes Of Colonic Other Causes Of Colonic BleedingBleeding

• ExcludeExclude

– IBDIBD

– NeoplasmNeoplasm

– AngiodysplasiaAngiodysplasia

– Ischaemic colitisIschaemic colitis

– Radiation proctitisRadiation proctitis

– VaricesVarices

Perforation (35% Mortality)Perforation (35% Mortality)

CT ScanCT Scan

Perforated diverticulitis

of the sigmoid colon-CT

CXRCXR

AXRAXR

Obstruction in Diverticular Obstruction in Diverticular DiseaseDisease

• Increased fibrotic reaction leads to stricturingIncreased fibrotic reaction leads to stricturing• Often present like cancer Often present like cancer • Progressive distension with faecal loadingProgressive distension with faecal loading

• Single contrast enema will delineate thisSingle contrast enema will delineate this

• Diagnosis Diagnosis – often only at operation (opened specimen) or often only at operation (opened specimen) or – on histologyon histology

FistulaFistula

• Abnormal connectionsAbnormal connections

• Colovaginal (esp if prev TAH)Colovaginal (esp if prev TAH)

• ColovesicalColovesical– PneumaturiaPneumaturia– Recurrent infectionsRecurrent infections– Faecalent urine or particulatesFaecalent urine or particulates

Duodenal and Jejunal Duodenal and Jejunal DiverticulosisDiverticulosis

• 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 Jejunal diverticula are acquired secondary to protrusions of the mucosal lining through the protrusions of the mucosal lining through the muscular wall of the bowel. muscular wall of the bowel.

• Vitamin deficienciesVitamin deficiencies– Increased colonic transit Increased colonic transit = Reduced Vit D (+Ca) + Iron= Reduced Vit D (+Ca) + Iron– SBBO SBBO = Reduced B12+ Increased Folate= Reduced B12+ Increased Folate

• Patients may present with anaemia and Patients may present with anaemia and osteomalacia.osteomalacia.

Proximal Jejunal Proximal Jejunal DiverticulitisDiverticulitis

Incidental Jejunal Incidental Jejunal DiverticularDiverticular

Proximal Jejunal diverticulitis Proximal Jejunal diverticulitis with perforationwith perforation

Further ReadingFurther Reading

• COLONIC DIVERTICULOSIS: A REVIEWCOLONIC DIVERTICULOSIS: A REVIEW

• Tyara Banerjee, Tyara Banerjee, • Suman Verma, Suman Verma, • Matthew W. Johnson.Matthew W. Johnson.

• Good Clinical CareGood Clinical Care

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