drexel university college of medicine colonic diverticular disease david e. stein, md division of...
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Drexel University College of Medicine
Colonic Diverticular Disease
David E. Stein, MD
Division of Colorectal Surgery
Department of Surgery
Drexel University College of Medicine
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Drexel University College of Medicine
Mrs P.
• 64 y/o female in the ER with LLQ pain, nausea and vomiting– History– Physical– ? Labs– ? Work-up
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Drexel University College of Medicine
Diverticular Disease
• Diverticulum is a saccular protrusion of mucosa through the colonic wall
• False vs True
• Pulsion
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Drexel University College of Medicine
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Drexel University College of Medicine
Prevalence
Asymptomatic diverticulosis• <45 years old: one-third; >80 years old: two-thirds
Hemorrhaging diverticulosis: 4%
Diverticulitis• >5 years disease: 10%• >20 years disease: 35%
Parks 1975, Kubo 1985, Horner 1958
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Drexel University College of Medicine
Types
Asymptomatic diverticulosis
Hemorrhaging diverticulosis
Acute diverticulitis
Subacute diverticulitis
Complicated diverticulitis
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Drexel University College of Medicine
Asymptomatic Diverticulosis
• Differentiated from IBS
• Doubtful role for operative therapy
• High-fiber diet• Anti-spasmodic agents
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Drexel University College of Medicine
Hemorrhaging Diverticulosis
Management• Assess hemodynamics• Establish baseline
laboratory values• Replace volume
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Drexel University College of Medicine
Hemorrhaging Diverticulosis
Investigations• Exclude upper gastrointestinal source• Proctoscopy• Colonoscopy• Radionuclide scintigraphy• Mesenteric angiography
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Drexel University College of Medicine
Colonoscopy
Prerequisites• Active or intermittent bleeding• Hemodynamically stable• Tolerant of intestinal lavage
Accuracy: 70-92%
Amenable to therapy: 17-39%
Jensen 1988, Rossini 1989, Richter 1995
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Drexel University College of Medicine
Radionuclide Scintigraphy
Modalities• Technetium-99m sulfur colloid• Technetium-99m-labeled red blood cells
Effectiveness• Incorrect localization: 48-60%• Incorrect operation: 42%
Hunter 1990, Bentley 1991, Voeller 1991
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Drexel University College of Medicine
Mesenteric Angiography
Effectiveness• Localization of bleeding site: 57-72%• Reduced operative mortality: 9-14% vs. 37-50%
Therapeutic options• Vasopressin infusion• Embolization
Britt 1983, Browder 1986, Uden 1986, Koval 1987
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Drexel University College of Medicine
Mesenteric Angiography
Vasopressin infusion• Initial control: 70-92%• Rebleed rate: 22-71%
Embolization• Initial control: 71-100%• Rebleed rate: 0-12%
Browder 1986, Guy 1992, DeBarros 1997, Szomstein 1997
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Drexel University College of Medicine
Hemorrhaging Diverticulosis
Operative indications• Persistent hypotension• Transfusion requirements:
– 6 units of blood over initial 24 hours– 10 units of blood
• Rebleeding within 7 days of cessation
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Drexel University College of Medicine
Acute Diverticulitis
Differential diagnosis• Malignancy• Inflammatory bowel disease• Ischemic colitis• Urologic/gynecologic disorders
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Drexel University College of Medicine
History and Physical
• Patients may have antecedent history of thinning bowel movements
• Patients may know they have “pockets”• All colonic pain is hypogastric – so bandlike pain
across the lower abdomen is common • No endoscopy or contrast enemas in the acute
phase – CT Scan
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Drexel University College of Medicine
Acute Diverticulitis
Investigations:• Ultrasonography• Water soluble contrast enema• Computerized tomography (CT)
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Drexel University College of Medicine
Ultrasonography
Diagnostic criteria• Hypoechoic wall thickening, hyperechoic
diverticulae, hyperechoic halo
Effectiveness• Positive predictive value: 96%• Negative predictive value: 98%
Schwerk 1992
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Drexel University College of Medicine
Contrast Enema
Diagnostic criteria• Mild: segmental narrowing, tethered mucosa,
mass effect• Severe: extraluminal gas/contrast
Effectiveness• Sensitivity: 94%; accuracy: 77%
Johnson 1987, Smith 1990
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Drexel University College of Medicine
Contrast Enema
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Drexel University College of Medicine
Computerized Tomography
Diagnostic criteria• Mild: Localized wall thickening (>5 mm),
pericolic fat inflammation• Severe: abscess, extraluminal gas/contrast
Effectiveness• Sensitivity: 93-97%
Cho 1990, Ambrosetti 1997
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Drexel University College of Medicine
Computerized Tomography
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Drexel University College of Medicine
Acute Diverticulitis
Outpatient management• Low-residue, low-fiber diet• Oral antibiotics
Inpatient management• Bowel rest• Intravenous antibiotics
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Drexel University College of Medicine
Acute Diverticulitis
Follow-up management (6 weeks)• Exclude malignancy
– endoscopy– contrast enema
• Exclude complicated diverticulitis– contrast enema– computerized tomography
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Drexel University College of Medicine
Acute Diverticulitis
First episode outcome• Fail medical therapy: 20%• Secondary complications: 20%
Recurrent episode(s) outcome• Secondary complications: 60%
Ambrosetti 1997, Farmakis 1997, Kohler 1999
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Drexel University College of Medicine
Acute Diverticulitis
Mild diverticulitis:• Fail medical therapy: 4%• Secondary complications: 14%
Severe diverticulitis:• Fail medical therapy: 30%• Secondary complications: 39%
Ambrosetti 1997
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Drexel University College of Medicine
Acute Diverticulitis
Special circumstances• Patients <50 years of age
– obese males
• Patients with compromised immune systems– transplant candidates
Schauer 1992, Ambrosetti 1994, Vignati 1995
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Drexel University College of Medicine
Operative Indications
Failed medical therapy
Resolved first episode• Severe diverticulitis• Age <50 years• Current or future immunosuppression
Resolved second episode
Complicated diverticulitis
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Drexel University College of Medicine
Subacute Diverticulitis
Diverticulae, pain, altered bowel habits
Pathology:• Acute/chronic inflammation: 82%
Clinical course:• Resolution of symptoms: 70%• Resolution of pain: 84%
Horgan 2000
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Drexel University College of Medicine
Complicated Diverticulitis
Perforation
Fistula
Obstruction
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Drexel University College of Medicine
Perforation
Considerations• Stage of peritonitis• Peri-operative factors• Operative alternatives• Outcome
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Drexel University College of Medicine
Staging Systems
Intra-operative systems• Hughes 1963• Hinchey 1978• Killingback 1983• Sher 1997
Peri-operative systems• Setti Carraro 1999• Biondo 2000
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Drexel University College of Medicine
Hinchey Stage I
Confined abscess• Paracolic• Intra-mesenteric
Hinchey 1978
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Drexel University College of Medicine
Hinchey Stage II
Distant abscess• Pelvic• Retroperitoneal• Intra-abdominal
Hinchey 1978
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Drexel University College of Medicine
Hinchey Stage III
Purulent peritonitis• Non-communicating• Obliterated neck of
diverticulum
Hinchey 1978
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Drexel University College of Medicine
Hinchey Stage IV
Fecal peritonitis• Communicating• Freely perforated
diverticulum
Hinchey 1978
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Drexel University College of Medicine
Peritonitis Severity Score
• Age• Underlying disease• Immunosuppressed• Hinchey peritonitis
score
Biondo 2000
• ASA score• Pre-operative organ
failure
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Drexel University College of Medicine
Preferred Staging Systems
Hinchey peritonitis score• American Society of Colorectal Surgeons• American College of Gastroenterology
Modified Hinchey peritonitis score• European Association of Endoscopic Surgery
Stollman 1999, Wong 2000, Kohler 1999
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Drexel University College of Medicine
Operative Preparation
• Broad-spectrum antibiotics• Percutaneous drainage of abscesses• Stoma marking and counseling• Reversal of deficits• Invasive monitoring• Ureteral stents
Ambrosetti 1992
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Drexel University College of Medicine
Diversion and Suture Closure
• Suture closure of perforation
• Omental pedicle• Proximal colostomy• Optional drainage
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Drexel University College of Medicine
Resection and Colostomy
• Resection of perforation
• Mucus fistula or closure
• Proximal colostomy• Optional drainage
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Drexel University College of Medicine
Resection and Anastomosis
• Resection of diseased segment
• On-table lavage• Primary anastomosis
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Drexel University College of Medicine
Resection and Diverted Anastomosis
• Resection of diseased segment
• On-table lavage• Primary anastomosis• Proximal stoma
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Drexel University College of Medicine
Resection and Anastomosis (I, II)
Stage Nondiverted Diverted Morbidity Mortality
I 53 4 22% 0%
II 15 11 30% 8%
Belmonte 1996
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Drexel University College of Medicine
Operative Alternatives (III, IV)
Procedure Mortality
Diversion and suture closure 26%
Resection and colostomy 12%
Resection and anastomosis 9%
Resection and diverted anastomosis 6%
Krukowski 1984
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Drexel University College of Medicine
Resection and Anastomosis (III, IV)
Author N Morbidity Mortality
Gregg 1987 17 48% 0%
Alanis 1989 34 50% 3%
Smirniotis 1992 6 33% 17%
Saccomani 1993 11 45% 4%
Total 68 47% 4%
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Drexel University College of Medicine
Operative Mortalitiy (III, IV)
Procedure Stage III* Stage IV
Diversion and suture closure 0/21 6/10
Resection and colostomy 6/25 2/6*P <0.05
Kronborg 1993
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Drexel University College of Medicine
Laparoscopy
E.A.E.S. consensus statement:
… in Hinchey I and II patients, the laparoscopic approach is not the first choice, but may be justified if no gross abnormalities are found …
… no place today for laparoscopic resections in Hinchey III and Hinchey IV patients …
Kohler 1999
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Drexel University College of Medicine
Summary: Hinchey Stage I
1. Non-operative management• Elective resection and anastomosis• Observation
2. Percutaneous abscess drainage• Elective resection and anastomosis
3. Urgent laparotomy/laparoscopy• Resection, lavage, and anastomosis
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Drexel University College of Medicine
Summary: Hinchey Stage II
1. Non-operative management and abscess drainage• Elective resection and anastomosis
2. Urgent laparotomy/laparoscopy• Resection, lavage, and anastomosis • Resection, lavage, and diverted anastomosis
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Drexel University College of Medicine
Summary: Hinchey Stage III
1. Emergent laparotomy• Resection and colostomy• Resection, lavage, and diverted anastomosis• Resection, lavage, and anastomosis• Diversion and suture closure
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Drexel University College of Medicine
Hinchey Stage IV
1. Emergent laparotomy• Resection and colostomy• Resection, lavage, and diverted anastomosis
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Drexel University College of Medicine
Fistula
Colovesical
Colocutaneous
Colovaginal
Coloenteric
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Drexel University College of Medicine
Colovesical Fistula
Symptoms• Cystitis: 70-80%• Lower abdominal pain: 30-90%• Pneumaturia: 60%• Fecaluria: 40-70%• Bowel symptoms: 65%
Pheils 1972, Woods 1988
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Drexel University College of Medicine
Colocutaneous Fistula
Etiology: post-operative: 95%; spontaneous: 5%
Signs: Fever, mass, obstruction, peritonitis, fistula
Factors associated with persistent fistula• Sepsis: 45%• Residual sigmoid colon: 40% • Crohn’s disease/carcinoma
Fazio 1987
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Drexel University College of Medicine
Colovaginal Fistula
Symptoms• Abdominal pain• Pus/stool/flatus passed per vagina
Signs• Vaginal os: ~75%• Pelvic mass
Woods1988
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Drexel University College of Medicine
Diagnosis
Colovesical fistula• Cystoscopy: 92%• Barium enema: 5-80%• Cystogram: 30%• Sigmoidoscopy• Computerized tomography
Woods 1988
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Drexel University College of Medicine
Diagnosis
Colocutaneous/colovaginal fistula• Fistulogram• Vaginogram• Barium enema• Endoscopy• Computerized tomography
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Drexel University College of Medicine
Treatment
Non-operative therapy
Operative therapy• Separation of organs by blunt dissection• Primary resection• Individualized repair of defect• Omentopexy
Amin 1984
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Drexel University College of Medicine
Obstruction
Etiology: perforation, recurrent episodes of diverticulitis, small bowel adhesions
Symptoms: abdominal pain, distention, constipation
Diagnosis: water-soluble contrast enema
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Drexel University College of Medicine
Obstruction
Non-operative therapy
Operative therapy• Emergent
– colostomy– resection with colostomy– resection, lavage, and anastomosis +/- loop ileostomy
• Elective– resection with anastomosis
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Drexel University College of Medicine
Summary
Diverticulosis is a common, age-related condition.
Hemorrhaging diverticulosis usually resolves but may warrant therapeutic angiography or resection.
Operative treatment of acute diverticulitis is reserved for failed therapy, first episodes with special circumstances, and most second episodes.
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Drexel University College of Medicine
Summary
Operative treatment is warranted for most episodes of complicated diverticulitis, including perforation, fistula, and obstruction.
The diseased bowel should be resected from supple colon proximally to rectum distally; excision of all diverticulae is unnecessary.
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Drexel University College of Medicine
Colonic Diverticular Disease
David E. Stein, MD
Division of Colorectal Surgery
Department of Surgery
Drexel University College of Medicine