Diverticular disease of GITBy Dr: Mohamed Ezzat

Demonstrator of surgical oncologyOncology Center Mansoura

University

before we startDef: A blind pouch that is continuous with the lumen of a hollow viscus.SitesTrue Vs FalsePulsion Vs traction

Diverticular disease of the colon

Incidence• Common in western

countries (50% above 65 years).• Urban areas > rural areas.• ln Egypt it is less common

and is seen more in younger age groups.

Etiology & PathogenesisChronic constipation>> ↑ intraluminal colonic pressure >>muscle spasm and incoordination>> herniation of colonic mucosa through the circular muscle layer between the taenia coli at the points of entry of blood vessels (pulsion diverticula).

False pulsion diverticula

SiteSigmoid colon in 90% of cases. Any area of the colon may be involved. Rectum is never affected (as taenia coli becomes a continuous layer).

Clinical picture

Asymptomatic (non complicated 80%)

Recurrent attacks of lower abdominal painDistension and flatulence.Accidentally discovered during enema (most common).

Symptomatic (Complicated 20 %)

1- Acute diverticulitis.As acute appendicitis but on the left sidePerforation.Fistula formation.

2- Chronic diverticulitis.colon stricture and adhesive intestinal obstruction.

3- Bleeding per rectum.

May be the first presentation

Massive bright red bleeding

Remember• The most common causes of massive

bleeding per rectum in old age are diverticular disease of the colon & angiomatous malformations.

• Colonic cancer is a common cause of fresh bleeding per rectum but not massive bleedings.

InvestigationsRadiologyBarium enema (Most important tool)Early >> Saw-tooth appearance.Late >> Well-developed diverticula can be visualized.

NB: Barium enema and colonoscopy are contraindicated in acute diverticulitis as they can cause perforation.

CT scanBest investigation in acute diverticulitis.lt reveals thickening of colonic wall, pericolic masses and abscesses.

Anqioqraphyln case of bleeding per rectum to localize the site of bleeding.

SigmoidoscopyWill detect the mouths of diverticula.Lt’s main value is to exclude carcinoma.Can detect bleeding from diverticula

TreatmentUncomplicated1. High-fiber diet.2. Anti-spasmodics for the abdominal colic.

ComplicatedAcute diverticulitisHospitilizationBed rest, bowel rest.Antibiotics.Regular monitoring.

Acute perforation >> Acute peritonitisClinical picture: Investigation: TTT : Explore , deal , toilet & drainage

Subacute perforation >> Localized abscess

Chronic perforation >> Fistula formationColovesicalColovaginalcolocutaneous

Intestinal obstructionConservativeSurgery

BleedingResuscitation followed by angiography to localize the site of bleeding.lf localized regional resection lf localization fails total colectomy + ileorectal anastomosis.

Meckel’s diverticulum

EtiologyPersistent patency of the proximal part of the vitellointestinal (Omphalomesenteric) duct.

Other anomalies?!

Incidence

• 2% of people are affected.• 2% of affected people may have

complications.• 2 times more common in males

than females.• 2 feet (60 cm) from ileocaecal

junction.• 2 inches long.

Clinical picture

Asymptomatic.CIP of complications.The most frequent manifestation is bleeding.

(The commonest cause of lower GIT bleeding in children) MCQ

Complications• Intestinal obstructionintussusception: the ectopic mucosa at the base of the diverticulum acts as FB and forms the apex of an ileoileal intussusception.Volvulus• Peptic Ulcer• Diverticulitis and perforation• Litter’s hernia

Q: Strangulated hernia without intestinal obstruction?

Differential diagnosis

• Appendicitis.• Salpingitis.• Perforated peptic ulcer.

TreatmentSymptomatic cases:Excise longitudinally and closed transversely

Asymptomatic cases (accidently discovered in laparotomy)

Young fit patient >> ExciseOld patient with comorbidity >> Leave it