Diverticular Disease

DR. RAJNISH

DR. ALTAMASH

Nomenclature

Diverticulum = sac-like protrusion of the gut wall

Diverticulosis = describes the presence of diverticuli

Diverticulitis = inflammation of diverticuli

Epidemiology

Before the 20th century, diverticular disease was rare

Prevalence has increased over time 1907 First reported resection of

complicated diverticulitis by Mayo 1925 5-10% 1969 35-50%

Epidemiology

Increases with age

Age 40 <5%

Age 60 30%

Age 85 65%

Epidemiology

Gender prevalence depends on age

M>>F Age less than 40

M > F Age 40-50

F > M Ages 50-70

F>>M Ages > 70

What exactly is a diverticulum?

Mostly Diverticulosis is actually not a true diverticulum but rather a pseudo-diverticulum True diverticulum contains all layers of the GI wall (mucosa to serosa), eg congenital diverticula, traction diverticula.

Pseudo-diverticulum more like a local herniaMucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa

1 Congenital. All three coats of the bowel are present in the wall of the diverticulum, e.g. Meckel’s diverticulum.

2 Acquired. The wall of the diverticulum lacks a proper muscular coat in most cases. Most alimentary diverticula are thought to be acquired.

TYPES OF DIVERTICULA

PULSION DIVERTICULA: develop at a site of weakness as a result of chronic pressure against an obstruction.eg, Epiphrenic diverticula, Zenker,s diverticula, most colonic diverticula

TRACTION DIVERTICULA:Fibrotic healing of the lymph nodes exerts traction on the oesophageal wall and produces a focal outpouching,eg Mid-oesophageal diverticula. It is a true diverticula

Anatomic location of diverticuli varies with the geographic location

“Westernized” nations (North America, Europe, Australia) have predominantly left sided diverticulosis 95% diverticuli are in sigmoid colon

5% diverticuli are from pharynx to descending colon Asia and Africa diverticulosis in general is rare and usually right

sided Prevalence < 0.2%

OESOPHAGEAL DIVERTICULA

1.Pharyngoesophageal

2.Midesophageal

3.epiphrenic

Small Intestine diverticulaMost of these diverticula arise from the mesenteric side of theBowel.

Duodenal diverticula

1 Primary. Mostly occurring in older patients on the inner wallof the second and third parts

2 Secondary. Diverticula of the duodenal cap result from longstandingduodenal ulceration

Jejunal And Meckel’s Diverticulum

It is a true diverticula

Occurs in 2% of patients, are usually 2 inches (5 cm) inlength and are situated 2 feet (60 cm) from the ileocaecalValve

It should be sought when a normal appendix is found atsurgery for suspected appendicitis

It represents the patent intestinal end of the vitellointestinal duct

Meckel’s Diverticulum

Classically Sigmoid 95% of all diverticuli

Rectal Sparing

The taeniae coalesce to form an enveloping muscular layer in the rectum. Much of the colonic wall is therefore devoid of longitudinal muscle and it is in these areas that diverticula form.

Colonic Diverticula

Diverticular Disease

Pathophysiology

Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

Mucosa

Submucosa

Muscularis

Serosa

Vasa recta

Diverticula do not arise randomly around the circumferenceof the colon

They originate in four distinct rows that correspond to the four sites of penetration of the bowel wall

by the major branches of the vasa recta:

On either side of the taenia mesocolica and on the mesenteric side of the taenia omentalis and taenia libera

The diverticula point to the mesenteric border, and no bona

fide diverticula arise from the antimesenteric intertaenial

area.

Diverticula maintain this fixed anatomic relationship to the taenia and are conspicuously absent from the portion of colon between the two antimesenteric taenia

Diverticular Disease-macroscopic

ENDOSCOPIC APPEARANCE OF COLONIC DIVERTICULA

Pathophysiology

Law of Laplace: P = kT / R

Pressure = K x Tension / Radius

Sigmoid colon has small diameter resulting in highest pressure zone

Pathophysiology Segmentation = motility process in which the

segmental muscular contractions separate the lumen into chambers

Segmentation increased intraluminal pressure mucosal herniation Diverticulosis

May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

Compounded by the hyperelastosis, increase in elastin deposition between the muscle cells in the taenia and altered collagen structure seen in the colon due to aging

Painter proposed a theory of segmentation,postulating that contraction of the colon at haustral folds caused the colon to act not as a continuous tube butas a series of discrete “little bladders,” which led to excessively high pressures within each segment

Lifestyle factors associated with diverticular disease Low fiber diverticular disease

Not absolutely proven in all studies but strongly suggested

Western diet is low in fiber with high prevalence of diverticulosis

In contrast, African diet is high in fiber with a low prevalence of diverticulosis

Lifestyle factors associated with diverticular disease

Obesity associated with diverticulosis – particularly in men under the age of 40

Lack of physical activity

Uncomplicated diverticulosis

Considered ‘asymptomatic’

However, a significant minority of patients will complain of cramping, bloating, irregular BMs, narrow caliber stools IBS? Recent studies demonstrate motility

abnormalities in pts with ‘symptomatic’ uncomplicated diverticulosis

Diverticular bleeding: Pathophysiology

Diverticulum herniates at site of vasa recta

Over time, the vessel becomes draped over the dome of the diverticulum separated only by mucosa

Over time, there is segmental weakening of the artery ruptures and bleeds

Diverticular bleeding: Pathophysiology

Diverticulitis

Diverticulitis = inflammation of diverticuli

Most common complication of diverticulosis

Occurs in 10-25% of patients with diverticulosis

Pathophysiology of Diverticulitis

Micro or macroscopic perforation of the diverticulum subclinical inflammation to generalized peritonitis

Previously thought to be due to fecaliths causing increased diverticular pressure; this is really rare

Pathophysiology of Diverticulitis

Erosion of diverticular wall from increased intraluminal pressure inflammation focal necrosis perforation

Usually inflammation is mild and microperforation is walled off by pericolonic fat and mesentery

MANAGEMENT OF DIVERTICULAR DISEASES

MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

MANAGEMENT OF SMALL INTESTINAL DIVERTICULA

MANAGEMENT OF LARGE INTESTINAL DIVERTICULA( COLONIC DIVERTICULA)

MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

DIAGNOSIS is confirmed by typical clinical presentations like: Dysphagia ,Regurgitation , Aspiration, Halitosis, excessive salivation, and a "lump in the throat" ,

TREATMENT:EndoscopicallyPouch excisionDiverticulopexy(pouch suspension)Myotomy of cricopharyngeous

INVESTIGATION: Barium swallow and endoscopy

A. Exposure of the esophagus and diverticulum is gained with a diverticuloscope placed perorally.

B. The linear stapler is placed across the cricopharyngeus muscle by placing a blade in the esophagus and the diverticulum.

ENDOSCOPIC PROCEDURE

MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

OPEN PROCEDUREThe linear stapler is placed across the neck of the diverticulum. Note that the bougie is in place before transecting the diverticulum

MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

Mid-oesophageal diverticula: Are usually traction diverticula of no particular consequence. The underlying motility disorder does not usually require treatment.

Epiphrenic diverticula:Large diverticula may be excised, and this should be combined with a myotomy from the site of the diverticulum down to the cardia to relieve functional obstruction

MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

Management 0f Duodenal diverticula

Mostly occurring in older patients

Usually asymptomatic.

Can cause problems locating the ampulla during endoscopic retrograde cholangiopancreatography (ERCP).

If symptomatic resection and anastomosis can be done

Management 0f Jejunal diverticula

Clinically, they may be symptomless give rise to abdominal Pain produce a malabsorption syndrome present as an acute abdomen with acute inflammation and occasionally perforation

TREATMENT:Resection of the affected segment with end-to-end anastomosis can be effective

Management of Meckel’s diverticulum

■ If a silent Meckel’s is found incidentally during the courseof an operation, it can be left alone provided it is widemouthed and not thickened

■ If ectopic gastric epithelium is present within thediverticulum, it may be the source of gastrointestinalbleeding, should be removed surgically

Meckel’s diverticulectomySteps in the performance of Meckelian diverticulectomy

Management of Meckel’s diverticulum

MANAGEMENT OF COLONIC DIVERTICULUM

Classic history: increasing OR constant, LLQ abdominal pain over several days prior to presentation with fever,

NATURE OF PAIN Crescendo quality – each day is worse Constant – not colicky Fever occurs in 57-100% of cases

Diagnosis is established by clasical history, physical examination and investigation

MANAGEMENT OF COLONIC DIVERTICULUM

Previous of episodes of similar pain

Associated symptoms Nausea/vomiting 20-62% Constipation 50% Diarrhea 25-35% Urinary symptoms (dysuria, urgency,

frequency) 10-15%

Contd.

Physical examination Low grade fever LLQ abdominal tenderness

Usually moderate with no peritoneal signs Painful pseudo-mass in 20% of cases Rebound tenderness suggests free

perforation and peritonitis

Labs : Mild leukocytosis 45% of patients will have a normal WBC

Contd.

Right sided diverticulitis tends to cause RLQ abdominal pain; can be difficult to distinguish from appendicitis

Contd.

Clinically, diagnosis can be made with typical history and examination

Radiographic confirmation is often performed Rules out other causes of an acute

abdomen Determines severity of the diverticulitis

Investigations

[Abdominal X-ray, barium study]

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.

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DOUBLE CONTRAST BARIUM STUDY

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- CBC, CT scan

Diverticular mass/paracolic abscess- CT scan

Investigations

Flexible sigmoidoscopy can visualise colonic diverticula. ( Colonoscopy may also be able to visualise affected segments)

CT SCAN FINDINGS

Treatment of Diverticulitis

Complicated diverticulitis = Presence perforation,

obstruction,

abscess, or fistula formation.

Uncomplicated diverticulitis = Absence of the above complications

Treatment of Uncomplicated diverticulitis

Bowel rest or restriction Clear liquids or NPO for 2-3 days Then advance diet Bulk purgatives

Antibiotics Lifestyle modification : weight control

Treatment Uncomplicated diverticulitis contd..

Monitoring clinical course Pain should gradually improve several

days (decrescendo) Normalization of temperature Tolerance of po intake

IF symptoms deteriorate or fail to improve with 3 days, then Surgery.

After resolution of attack high fiber diet with supplemental fiber is advised

Treatment Uncomplicated diverticulitis contd..

Follow-up: Colonoscopy in 4-6 weeks

Flexible sigmoidoscopy and BE reasonable alternative

Purpose Exclude neoplasm Evaluate extent of the diverticulosis

Prognosis after resolution of uncomplicated diverticulitis

30-40% of patients will remain asymptomatic

30-40% of pts will have episodic abdominal cramps without frank diverticulitis

20-30% of pts will have a second attack After a second attack elective

surgery

Prognosis after second attack

Second attack Risk of recurrent attacks is high (>50%)

Some studies suggest a higher rate (60%) of

complications (abscess, fistulas, etc) in a second attack and a higher mortality rate (2x compared to initial attack)

Some argue elective surgery should be considered after a first attack in

Young patients under 40-50 years of age Immunosuppresed

Treatment of complicated diverticulitis

Treatment Complicated Diverticulitis: AbscessHINCHEY CLASSIFICATION

Stage I Diverticulitis with associated pericolic abscess

Stage II Diverticulitis associated with distant abscess (retroperitoneal or pelvic)

Stage III Diverticulitis associated with purulent peritonitis

Stage IV Diverticulitis associated with fecal peritonitis

STAGE i and STAGE ii is suitably managed with drainage and antibiotics

STAGE iii and STAGE iv usually requiring surgery

Small <5 cm abscesses may resolve with antibiotic therapy

Patient with larger abscesses or those who falls to improve with antibiotics should undergo CT guided percutaneous drainage

Colonic resection is indicated for those who develop either recurrent diverticulitis or another abscess

Treatment Complicated Diverticulitis: Abscess

CT- GUIDED DRAINAGE OF DIVERTICULAR ABSCESS:

Patient with abscess larger than or equal to 4 cm can be managed with CT guided abscess drainage followed by elective surgery after resolution.

Complicated Diverticulitis: Fistulas

Occurs in up to 80% of cases requiring surgery

Major types Colovesical fistula 65% Colovaginal 25% Coloenteric, colouterine 10%

COLOVESICAL, COLOUTERINE AND COLOVAGINAL FISTULAE

Complicated Diverticulitis: Fistulas – Symptoms-

Passage of gas and stool from the affected organ

Colovesical fistula: pneumaturia, dysuria, fecaluria

50% of patients can have diarrhoea and passage of urine per rectum

Complicated Diverticulitis: Fistulas

Diagnosis CT: thickened bladder with associated

colonic diverticuli adjacent and air in the bladder

BE: direct visualization of fistula track only occurs in 20-26% of cases

Flexible sigmoidoscopy is low yield (0-3%) Some argue cystoscopy helpful

Complicated Diverticulitis: Treatment of colovesical Fistulas

Two Approach to treat colovesical fistula

1.Conservative: Without bowel resection by closing the fistula and interposing omentum between bowel and bladder.

2.Conventional: Pinching off the affected bowel from the bladder, resect the sigmoid and perform end to end anastomosis.

Bladder hole is left open and put urethral catheter for free drainage

Treatment of Complicated Diverticulitis:With generalised peritonitis

Surgery is principally directed to control sepsis in the peritoneum and circulation.

Vigorous resuscitation and antibiotic therapy is still warranted.

Opoid analgesia. Oxygen therapy. Urinary catheter to assess hourly urine out put Resection of sigmoid colon and colorectal anastomosis Primary resection and anastomosis after on table lavage

in selected case. Hartman’s procedure : Resection of sigmoid colon with

formation of end colostomy when condition do not favour primary anastomosis

Treatment of Complicated Diverticulitis:With obstruction/stricture

Symptoms: pain,increasing constipation, passage of ribbon like stools

However majority of patient presents with classic symptoms of large bowel obstruction

Diagnosis is confirmed by ; patient’s history, physical examinations and radiological confirmation either by contrast enema or CT with oral/rectal contrast

Treatment of Complicated Diverticulitis:With obstruction/stricture

Conservative approach: Metallic stents to releive colonic obstruction.

Endoluminal wall stents: shown to be safe and effective in decompressing obstruction

Surgery: Hartman’s resection and resection with primary anastomosis rarely with loop ostomy is the procedure of choice.[Hartmann procedure is two stage procedure includes- Colostomy Sigmoid resection Rectal stump 3 months later colostomy takedown and colorectal

anastomosis

Diverticular bleeding: Symptoms

Most only have symptoms of bloating and diarrhea but no significant abdominal pain Painless hematochezia Start – stop pattern; “water faucet”

Diverticulitis rarely causes bleeding

Diverticular bleeding:Management

Most common cause of brisk hematochezia (30-50% of cases)

15% of patients with diverticulosis will bleed

75% of diverticular bleeding stops without need for intervention

Patients requiring less than 4 units of PRBC/ day 99% will stop bleeding

Risk of rebleeding 14-38%

Diverticular bleeding:Management

Resuscitation

Localization

Supportive care with blood products

Diverticular bleeding: Localization

Right colon is the source of diverticular bleeding in 50-90% of patients

Possible reasons Right colon diverticuli have wider necks

and domes exposing vasa recta over a great length of injury

Thinner wall of the right colon

Diverticular bleeding:Localization

Colonoscopy after rapid prepration Can localize site of bleeding

Offers possible therapeutic intervention (cautery, clip, etc)

Diverticular bleeding:Management ( Cauterization )

A site of active bleeding was identified

Treated successfully with placement of two hemoclips

Diverticular bleeding:Management

Diverticular bleeding: Surgery

Surgery Segmental resection

If site can be localized Rebleeding rate of 0-14%

Subtotal colectomy Rebleeding rate is 0% High morbidity (37%) High mortality (11-33%)

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