colonic diverticulosis neo

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  • 1. Diverticular disease Dr nawin kumar

2. from the oesophagus to the rectosigmoid. Types 1. Congenital or true- 3 layers 2. Acquired or false- lacks a proper muscular coat 3. Small intestine Mesenteric side mucosal herniation through the point of entry of blood vessels. 4. Duodenal diverticula 1. Primary- in older patients on the inner wall of the 2nd n 3rd parts found incidentally Usually asymptomatic problems locating the ampulla during ERCP 1. Secondary Diverticula of the duodenal cap from long-standing duodenal ulceration 5. Jejunal diverticula variable size and multiple common in patients with connective tissue disorders Variable clinical presentation 1. Symptomless 2. abdominal pain 3. malabsorption syndrome- giving rise to anaemia, steatorrhoea, hypoproteinaemia and vitamin B12 deficiency resection of the affected segment with end-to-end anastomosis can be effective 1. acute abdomen 1. acute inflammation 2. Perforation. 6. Meckels diverticulum 7. Diverticulosis of colon outpouchings of the mucous membrane false diverticula most commonly found in the descending and sigmoid colon occur at weak points in the circular muscle layer, where the blood vessels supply the mucosa Disease of The Western World 8. 60% over the age of 60 years Rare before 40 9. Affects more to females 10. most commonly found in the descending and sigmoid colon Recum spared 11. Rare in asian n african In Asia right-sided diverticular 2x 12. Saints triad Diverticulosis hiatus hernia gall stones 13. Aetiology Why colon is common site 14. Laplace law The larger the vessel radius, the larger the wall tension required to withstand a given internal fluid pressure. 15. Aetiology a weak colonic wall and High intraluminal pressure 16. weak colonic wall anatomic features intrinsic to the colon Longitudinal layer alterations in colonic wall with aging Genetically weak colonic wall defects in collagen consistency 17. High intraluminal pressure factors Physiological factors Motor dysfunction Lower colonic motility Colonic wall compliance Abnormal intraluminal pressures Dietary factors Diet low in fibre Chronic constipation 18. Low-fibre diets distend the colon less than high-fibre diets high intramural pressures. Refined, low-fibre diets may also relate to muscle spasm and muscular hypertrophy of the wall of the sigmoid colon high intraluminal pressures. 19. Aetiology Other factors Alcohol smoking Corticosteroid therapy 20. result herniation of the mucosa between the taenia coli at sites of least resistance (where blood vessels pierce the circular muscle.) They tend to occur in rows between the strips of longitudinal muscle, some-times partly covered by appendices epiploicae 21. stages 22. diverticulosis 90% Asymptomatic Vague complain- Discomfort Fullness Bloating flatulance x ray- Saw tooth appearance 23. spectrum of diverticular disease Diverticulitis Pericolic abscess Peritonitis Intestinal obstruction- In sigmoid -progressive fibrosis causing stenosis In small intestine - adherent loops to pericolitis Haemorrhage Fistula formation 24. Acute diverticulitis Faeces obstructs the neck of a diverticulum inflammation. 25. Acute diverticulitis left-sided appendicitis Change in bowel habit eg.constipation Bloody or purulent stool pain- colicky abdominal pain Tenderness- suprapubic, shifting to left iliac fossa. Local signs of peritonitis Mass- tender, firm,nonmobile,resonant Fever, nausea and vomiting raised WCC 26. Aetiology "Thumbprinting" is a radiological sign of thickening of the colonic wall (seen in left mid quadrant on this plain abdominal radiograph). It occurs secondary to submucosal haemorrhage oedema from capillary leakage. It can occur due to anything that leads to oedema of the bowel, including diverticular disease. 27. Pathogenesis Thickening of the bowel wall in the descending colon due to bowel oedema can be seen in the left lower quadrant on this CT scan from a 62 yr old patient with diverticulitis. The hypodense (dark) spot in the bottom right of the edematous colonic wall is an abscess that is forming within the bowel wall. This is a CT scan of sigmoid diverticulitis in a 50yr old male patient with a history of diverticulosis and left lower abdominal pain and tenderness. 28. Presentation 29. Presentation Patient presents with complications of diverticular disease, acute - chronic. Acute diverticulitis - Faeces obstructs the neck of a diverticulum inflammation. - Marked by suprapubic pain, shifting to left iliac fossa. - Fever, nausea and vomiting. - left-sided appendicitis. - Local signs of peritonitis, colicky abdominal pain, raised WCC. - Change in bowel habit eg.constipation. Perforated diverticulitis - Sudden onset of pain with generalised peritonitis. - Shocked - Free gas on erect chest X-ray. Diverticular abscess - Perforated diverticulum contained by anatomical structures local abscess. - Abdominal mass on examination. Fistulas most commonly with bladder. - Colovesical fistula; cystitis, pneumaturia, recurrent UTIs and faecal debris in the urine. - Colovaginal fistula; faecal discharge per vagina. - Fistula with the small intestine diarrhoea. Haemorrhage - Diverticula erode into adjacent blood vessels. - Sudden rush of bright or dark red blood per rectum. - Usually painless. 30. Investigations [Abdominal X-ray, barium study] Flexible sigmoidoscopy can visualise colonic diverticula. Colonoscopy may also be able to visualise affected segments, but the sigmoid colon is often rigid and narrow in diverticular disease which can make it hard for the scope to progress. Barium enemas show diverticula as globular outpouchings on X- ray film. They typically have a signet-ring appearance due to the filling defect produced by contained faecoliths. 31. Investigations Diverticular strictures can simulate annular carcinomas on barium X-ray as both have an apple-core appearance. Therefore an endoscope is also needed for confirmation. Diverticulosis- barium enema (colonoscopy) Diverticulitis- FBC, WCC, U+E, chest x-ray, CT scan Diverticular mass/paracolic abscess- CT scan 32. Investigations Perforation- plain film of abdomen, erect chest X-ray, CT scan Obstruction- gastrograffin or dilute barium enema, colonoscopy to exclude underlying malignancy. Acute obstruction requires a laparotomy to establish the diagnosis of diverticulitis. Fistula; colovesical- MSU, cystoscopy, barium enema colovaginal- colposcopy, flexible sigmoidoscopy Haemorrhage- colonoscopy, selective angiography 33. Management Diverticulosis managed with dietary advice (increased fibre, increased fluids). Uncomplicated symptomatic disease managed similarly, with a well- balanced diet and smooth-muscle relaxants if necessary. Anti-spasmodics sometimes helpful. Avoid stimulants. Anastamoses for bowel resection must be made with rectum to avoid recurrence Acute attacks of diverticulitis treated with cephalosporin and metronidazole. - Serious cases may require hospital admission for bowel rest, i.v fluids, and antibiotic therapy. Diverticular abscesses initially managed as above. - Paracolic abscesses can purulent / faeculent peritonitis. Usually drained surgically / under radiological guidance. -Sometimes need resection and Hartmanns procedure. 34. Management Perforated diverticulitis usually needs a laparotomy for diagnosis confirmation. - Also for washing-out contamination from abdominal cavity and resection of sigmoid colon. - Hartmanns procedure with temporary left iliac fossa colostomy. Acute obstruction requires resection of the affected segment of colon (bowel brought out as end colostomy). Fistula formation requires an elective colectomy and closure of the fistula. Haemorrhages usually stop spontaneously. - Angiography and bowel resection may be needed. Post-inflammatory strictures may require elective resection of colon. - If no acute inflammation or abscesses present, can perform a primary anastamosis. - Biopsy all colonic strictures to exclude underlying carcinoma. 35. Course & Prognosis 10-20% of patients experience complications, mainly diverticulitis and lower GI bleeding. Conservative management of diverticular disease is preferred. Surgery reserved for major complications. In UK, surgery usually for cases of diverticular disease fistulas, obstruction, haemorrhage or recurrent inflammation. The Hinchey staging system used to reflect surgical outcome and risk of secondary complications after managing the acute episode of diverticular disease. 33% of patients with a first attack of diverticulitis will have a recurrence. 2-3 recurrences within 2 years are an indication for removal of the affected colonic segment. The prognosis for diverticular disease is good with early detection and treatment of complications. 36. 80-85 % of patients with DD remain asymptomatic 15-20 % of patients presenting abdominal pain /complication 37. Complications Diverticulitis Peridiverticulitis Pericolic/Paracolic abscess Bleeding Intestinal obstruction 38. Complications Fistula Colovesical Coloenteric Colocutaneous Colovaginal 39. Diverticulitis Severe pain Recurrent episodes Guarding and rigidity Perforation frank peritonitis Fecal peritonitis 40. Peridiverticulitis Fever Pain Inflammatory mass Organized perforated diverticuli 41. Peridiverticulitis Paracolic abscess Leads to fistula 42. Investigations Colonoscopy Barium enema CT scan Investigations (same as LOWER GI BLEED)


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