diverticulitis robert zaid pgy-1 october 24, 2005 genesys regional medical center
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Diverticulitis
Robert Zaid PGY-1
October 24, 2005
Genesys Regional Medical Center
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Barcelona - Gaudi
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DiverticulitisOutline
• Definition• Pathophysiology• Epidemiology• Clinical presentation• Differential• Imaging• Laboratory• Treatment• Reasons for surgery
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DiverticulitisDefinition
• Diverticula – Etiology• Outpouchings
– Occur in areas weak and under stress
– Prolapse of mucosa and submucosa may occur.
• Location– Arteries penetrate the muscularis to
reach the submucosa and mucosa.
– Diverticula form through entire colon
» Left colon
» Sigmoid (most common)
» Right sided (uncommon)
http://health-pictures.com/diverticulitis-picture.htm
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisDefinition
• Diverticulitis – Fecalith becomes impacted in a diverticulum
– Erosion through the serosa • Perforation
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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Citadel Park
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DiverticulitisPathophysiology
• Diverticula– Acquired or congenital– Can affect small or large intestine– May be related to an increase in intramural
pressure– Occurs in the weakest areas of the colonic
wall• Adjacent to the vasa recta• Mesenteric side of the colon
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
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DiverticulitisPathophysiology
– Theories• Deficiency in dietary fiber
– Western diet– Decreased fecal bulk– Narrowing of the colon– Small fecal mass
» Increased intraluminal pressure needed to move material
• Loss of tensile strength• Decrease in elasticity
– Proof?• High fiber diet appears to decrease incidence
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8 th edition, 1999
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DiverticulitisPathophysiology
• Diverticula– False diverticula (pulsion)
• Herniation through colonic wall– Mucosa– Muscularis
• Occur between tenia coli– Points of weakness
• High intraluminal pressure• Bleeding is self limiting
– True diverticula• Rare and usuall congenital• Comprise all layers of bowel wall
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8 th edition, 1999
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DiverticulitisPathophysiology
• Diverticulitis – Inflammation in and around a diverticulum– Stagnation of nonsterile inspissated fecal material (fecalith)
• May compromise the blood supply• Cusing inflammatory erosion of the mucosal lining • Perforation
– Intramural abscess– Fibrinous exudate– Abscess formation– Local adhesions– Peritonitis– Sealed-off abscesses – Contained sinus tracts – Fistulas
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
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La Familia
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DiverticulitisEpidemiology
• Frequency in US– Diverticular disease
• 5% of population at age 40• 33-50% of population older than 50• 80% of population older than 80
– Diverticulitis• 10-20% of patients with diverticular disease
• Frequency internationaly• Diverticulosis occurs in 0.2% of population
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
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DiverticulitisEpidemiology
• Mortality and Morbidity– 20% require surgical therapy– Mortality rate of 7.7% (if peritonitis is present)
• Race– Asians predisposed to right sided diverticulitis
• Sex– No relationship
• Age– Disease increases with age
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
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DiverticulitisClinical Manifestations
• Symptoms– Pain
• Typically located in left lower quadrant• Subacute and constant pain• Right sided diverticulitis can occur (congenital?)
– Fever • Almost invariably present• High-grade fever and sepsis
– If perforation is not contained or – When the peritonitis is generalized
– Constipation or loose stools may be reported– Rectal bleeding is unusual.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisClinical Manifestations
• Fistulas occur in 5% of patients w/ complicated diverticulitis– Colovesical– Colovaginal– Coloenteric
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisDifferential Diagnosis
• Lower abdominal pain, fever, and bloody diarrhea – Bacterial colitis (Shigella,
Salmonella, Campylobacter)– Ischemic colitis– Inflammatory bowel disease
• Generalized peritonitis– Acute abdomen
• Gynecologic disorders – May be localized to the left
lower quadrant (LLQ)
Acute severe abdominal pain – Perforation of an abdominal viscus
• Peptic ulcer• Small bowel obstruction• Choledocholithiasis • Nephrolithiasis• Rupture and dissection of an abdominal aortic
aneurysm – Subacute onset of pain
• Intestinal ischemia • Cholecystitis• Pancreatitis • Diverticulitis• Crohn's disease • Appendicitis
– Pain of a constant nature• Cholecystitis• Pancreatitis• Intestinal ischemia• Inflammatory disorders
– Colicky pain occurs • Nephrolithiasis • Intestinal obstruction
– Radiation of pain • Pancreatitis• Peptic ulcer disease• Biliary tract disease
– Shoulder pain • Diaphragmatic irritation
– Significant vomiting is seen with pancreatitis or obstruction of the stomach or small bowel.
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DiverticulitisLaboratory
• Leukocytosis – Common, nonspecific
• Urinalysis – Protein or rare white blood cells may be found
• Nonspecific
• Fecal leukocytes • Should be sought if diarrhea is present
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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Candy Factory
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DiverticulitisImaging
• Abdominal radiographs – May indicate
• A displaced colon• Extraluminal gas• Colonic mucosal abnormalities
– More helpful in excluding other potential causes of left lower quadrant pain.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
![Page 20: Diverticulitis Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center](https://reader036.vdocuments.mx/reader036/viewer/2022062314/56649d265503460f949fd88d/html5/thumbnails/20.jpg)
DiverticulitisImaging
• Abdominal CT– Test of choice– May demonstrate
• Bowel wall thickening• Abscess formation• Diverticula
• Diagnostic barium enema – Safe when carefully performed– Findings include
• Spiculation of the mucosa• Spasm• Frank perforation • Abscess
– Findings specific for diverticulitis, but may be hard to distinguish from carcinoma
• CT and barium enema are complementary – Neither is 100% sensitive or specific.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisImaging
• Computed tomographic scan – Marked thickening of
• Distal end of the descending colon
– Inflammatory changes (straight arrow)
– Extraluminal gas (curved arrow)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisImaging
• Barium Enema– Colon with sinus
formation – Shows multiple
diverticula– Communicating sinus
is clearly seen (arrow).
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisImaging
• Endoscopic examination– Contraindicated with diverticulitis– Theoretical potential to exacerbate perforation– Can detect diverticulosis before or between
attacks
• Sigmoidoscopy– Appropriate when
• Carcinoma or• Inflammatory bowel disease is highly suspected
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisImaging
• Colonoscope– Wide-mouthed
openings to diverticula – Colonoscopy may be
difficult and hazardous when diverticula are large enough to admit the tip of the scope.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
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Street entertainers
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DiverticulitisTreatment
• Mild diverticulitis – Initially (symptoms usually disappear rapidly)
• Rest• A liquid diet• Oral antibiotics
– After a few days• Soft, low-fiber diet and take a daily psyllium (i.e. metamucil) seed preparation.
– After 1 month• A high-fiber diet can be started
• Severe symptoms— (perforation, peritonitis)– Admitted to hospital– Intravenous fluids and antibiotics– Bedrest– Nothing by mouth until the symptoms subside
About 20% of people who have diverticulitis require surgery because the condition does not improve.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
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DiverticulitisTreatment
• Inpatient– Broad-spectrum antibiotics
• Third-generation cephalosporin – Ceftriaxone 1.5mg intravenously daily
• Anaerobic coverage – Metronidazole 250mg intravenously three times daily
– At discharge• Oral antibiotics to complete 14 day course• Ciprofloxacin and Metronidazole)
• Outpatient (mild disease)– Oral antibiotics (14 days)
• Ciprofloxacin (500mg twice daily) • Metronidazole (250mg three times daily) for 14 days
– Bowel rest
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisTreatment
• Colon carcinoma may mimic diverticulitis– Colonoscopy or sigmoidoscopy is
recommended 4-6 weeks after recovery when surgery is not performed
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8 th edition, 1999
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DiverticulitisTreatment
• Early surgical consultation is important– Especially in the presence of significant pain
or – An acute abdomen
• Percutaneous catheter drainage – If large abcess is present
• Temporary
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
![Page 30: Diverticulitis Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center](https://reader036.vdocuments.mx/reader036/viewer/2022062314/56649d265503460f949fd88d/html5/thumbnails/30.jpg)
DiverticulitisTreatment
• Some reasons for surgery– Colonic stricture– Bleeding– Fistula formation to
• The small bowel• Colon• Bladder• Vagina
Surgcial resection– Warranted in reoccurrences (1/3 of all patients)– Sigmoid colectomy with anastamosis
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
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DiverticulitisTreatment
• Hinchey staging– Stage I
• Colonic inflammation• Pericolic abcess
– Stage II• Colonic inflammation• Retroperitoneal or• Pelvic abcess
– Stage III• Purulent peritonitis
– Stage IV• Fecal peritonitis
• Percutaneous drainage?
• If not….– Sigmoid colectomy w/
primary anastamosis• Stage I or II
– Sigmoid colectomy w/ hartman pouch
• Larger abcesses
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8 th edition, 1999
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Festivals
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DiverticulitisReasons for Elective Surgery • CONDITION1. Two or more severe attacks of
diverticulitis (or one severe attack in someone younger than 50)
2. Narrowing of the sigmoid colon (lower part of the large intestine) due to scarring
3. Persistent tender mass in the abdomen
4. X-ray showing suspicious changes in the sigmoid colon
5. Pain when urinating
6. Sudden abdominal pain in people taking corticosteroids
• REASON1. High risk of serious complications
2. High risk of serious complications
3. May be cancer
4. May be cancer
5. May be a warning of impending fistula formation between the large intestine and the bladder
6. Large intestine may have ruptured into the abdominal cavity
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
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Any questions?