Diverticulitis and Management issues

Prakash K

Diverticular Disease• In the US, individual risk of 50% by age 60.

• Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisations

• 25% of patients with diverticulitis will present with a complication leading to surgery

• Diverticulitis is one of the five most costly GI disorder in the US population

299 pts out of 3022 colonoscopies

258 (85%) were incidental

40% right sided

46% Left colonic

13% pan colonic

Etiology

•Age – In the United States▫1/3 by age 60▫2/3 by age 85

•Obesity•Diet – Western diet

▫Low fiber▫High meat consumption▫High sugar consumption

•Distribution – more common in industrialized countries

Effect of the Industrial Revolution

No pathologic

specimens in European

museums or case

reports of diverticulitis

or diverticulosis prior

to Industrial Revolution

(~1750-1850)

Effect of the Industrial Revolution

Process of roller-milling wheat lead to decrease in fiber consumption

Increased consumption of meat and sugars by the general population

25 year lag between roller-milling and the first cases of diverticulitis

Diverticulitis•

▫ 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)

Etiology of Diverticulosis

DiverticulitisTheories

Increased intraluminal pressure Current theory based on

epidemiological studies Decrease in fiber in the

diet Hypertrophy of the

colonic wall Increase pressure to

propel stool through the colonFiber rich diet – sigmoid

pressure = atmosphericLow fiber diet – sigmoid

pressure = 90mmHg

▫ Fecalith becomes impacted in a diverticulum

▫ Erosion through the serosa Perforation

Theories

Increased intraluminal pressure

Current theory based on

epidemiological studies

Decrease in fiber in the diet

Hypertrophy of the colonic wall

Increase pressure to propel

stool through the colon

Fiber rich diet – sigmoid

pressure = atmospheric

Low fiber diet – sigmoid

pressure = 90mmHg

Definitions

Diverticulum: saccular outpouching of thecolonic wall.• Diverticulosis: presence of diverticuli

withoutcomplications• Diverticulitis: presence of peridiverticularinflammation or infection• Complicated presentations: perforation,obstruction, stricture, fistula, or

hemorrhage.• Phlegmon: not condsidered as

complication

Incidence

Rare under 30

40% @ 60, 60% > 80

95% sigmoid and left colon

Progressively more

proximally in Asian

countries

10-25% develop

diverticulitis

Diverticular Disease• In the US, individual risk of 50% by age 60.

• Diverticulitis occur in 20 to 30% of patient and is one of the most common GI related hospitalisations

• 25% of patients with diverticulitis will present with a complication leading to surgery

• Diverticulitis is one of the five most costly GI disorder in the US population

Diagnostic imaging: CT Scan

CT scan has emerged as the study of choice

• Advantages:– Ability to make accurate diagnosis– Stage the severity– Therapeutic ability to drain an abscess

with CTguidance– Assess extraluminal findings

CT findings

• Presence of diverticuli

• Pericolic fat stranding

• Colonic wall thickening more than 4 mm

• Abscess formation.

• Intraperitoneal findings may include; hepatic

abscesses, pyelophlebitis, small bowel

obstruction, colonic strictures/obstruction,

and colovesical fistulas.

Classification systems

•• Ambrosetti

•• Modified Hinchey

Ambrosetti CT criteria

• Mild diverticulitis– Wall thickening (>5 mm)– Pericolic fat stranding• Severe diverticulitis– Wall thickening (>5 mm)– Pericolic fat stranding with– Abscess– Extraluminal air– Extraluminal contrast

Modified Hinchey classification

Stage 0: Mild clinical diverticulitis

• Stage Ia: Confined pericolic infl. – phlegmon

• Stage Ib: Confined pericolic abscess(sigmoid)

• Stage II: Pelvic, distant

intra-abd/intraperitonal abscess

• Stage III: Generalized purulent peritonitis

• Stage IV: Fecal peritonitis

Management

Controversies

•“Uncomplicated diverticulitis may be managed as an outpatient (dietary modification and oral antibiotics) for those without appreciable fever, excessive vomiting, or marked peritonitis, as long as there is the opportunity for follow-up.”

ASCRS Guidelines

Rafferty J, DCR 2006

Practice Parameters

•Elective resection after two documented attacks of diverticulitis

•Complicated diverticulitis: resection after the first attack

•Patients below 40, after first attack

Stage 0

Generally treated with

Oral antibiotics

Ciprofloxacin+metro

nidazole

Cephalosporins+metr

o

Low residue diet

initially

High fiber diet once

symptoms resolve

Interval colonoscopy

Stage Ia

Follow up of Stage 0 and Ia

•Careful history regarding prior attacks

including number, frequency, and severity

•Interval Colonoscopy to rule out

malignancy

•High fiber diet

•<25% will have second attack

•Risk of third attack >50% after second

attack

Stage Ib or IIComplicated Diverticulitis•Close follow up to assure resolution of

symptoms• Interval colonoscopy to rule out malignancy

•Segmental resection with primary anastomosis 4-6 weeks after episode

Laparoscopic approach•Risk of recurrence if managed conservatively

secondary to complications of diverticulitis (abscess, stricture or fistula)

Stage III and IVComplicated Diverticulitis

• Can be difficult to

distinguish on CT

Scan or clinically

• Generalized or

Localized Peritonitis

• Sepsis

• Fever

• Elevated WBC

Perforated Diverticulitis ( Hinchey stages 3 and 4 )Ideal operation ?

1-Primary resection with Hartmann pouch

2-Primary resection with anastomosis and temporary ileostomy

3-Primary resection with anastomosis and no temporary stoma

4-Simple laparoscopic washout with drainage

controversies1. Is outpatient adequate for Stage and 1?

2. Does one have to avoid seeds nuts and popcorn if they have diverticulitis/diverticulosis?

3.When do you operate on diverticulitis?

4. Do all young patients (age < 50) require sigmoid colon resection?

5.Recommendation for immunosuppressed?

How successful is outpatient tx?• Research Study:

Kaiser ED et al for diverticulitis Kaiser member 5 yrs prev, no prior dx of

tics CT scan 1 day of eval Not admitted Excluded: no antibiotic rx 1 day of eval

▫Outcome: Re-eval/ admission for within 60 days

• Results:▫n = 693, overall failure rate 5.6%

Etzioni et al, DCR 2010

2.Can we eat Seeds, Nuts and Popcorn?•JAMA August 2008•“Nut, Corn and Popcorn Consumption and

the Incidence of Diverticular Disease”•Health Professionals Follow-up Study•Cohort of US men (51,529) followed

prospectively from 1986 – 2004•Follow diet, life style and medical history

with biennially questionaire•90% mean followup

Can we eat Seeds, Nuts and Popcorn?

•Supplemental questionairre sent to 47,228 (after exclusions) men in 2004

•Looked at nut, corn and popcorn consumption and symptomatic diverticulitis

•Conclusion: Nut, corn and popcorn consumption did not increase the risk of diverticulosis or diverticular complications

• Inverse associations between nut and popcorn consumption and the risk of diverticulitis in patient’s who consumed them >2x/week

Nuts popcorn

• 2.5g fiber per 1 oz

• Vitamin E

• ↓CRP and IL-6 levels

• Rich in Zinc and

Magnesium

• Anti-inflammatory

properties

• 3.6g fiber per 3cup

• Lutein – micronutrient

with anti-

inflammatory and

chemoproctective

properties

Can we eat Seeds, Nuts and Popcorn?

Yes!

Do all young patients (age < 50) require sigmoid colon resection?

Do all young patients (age < 50) require sigmoid colon resection?

•Natural history of diverticular disease seemed to suggests that it behaves in a more virulent manner

•More severe first attack with more patients having complicated diverticulitis at the time of first episode

•Historically lead to the recommendation that sigmoid resection be performed after the first episode

•10-25% of diverticulitis patient <50 years old

Do all young patients (age < 50) require sigmoid colon resection?

• Guzzo et al Dis Colon Rectum 2004▫ Studied patient’s <50 who were treated

conservatively after one episode▫ 1:196 had subsequent perforation

• Nelson et al Dis Colon Rectum 2006▫ Compared the outcomes of patient’s <50 with

patients >50 treated conservatively and found no difference in outcomes

• Pautrat et al Dis Colon Rectum 2007▫ Compared patient’s in 40’s with patient’s in 50’s▫ Found those in their 40’s were more likely to have

more severe disease with more complications

Do all young patients (age < 50) require sigmoid colon resection?

A more selective approach seems warranted especially in the patient with uncomplicated diverticulitis at their first presentation

Patient less than 40 may have a more virulent course but this has not been well established

After two episodes one should seriously consider elective resection

5.In the immunocompromisedIncreased likelihood of free perforation and fecal

peritonitis• Clinical presentation often underestimates the severity• Very large percentage will fail standard, nonoperativetreatment• Most require urgent surgical intervention, associatedwith a higher mortality rate – 39 vs 2% in

noncompromised patients• American society of colon and rectal surgeonsrecommend elective sigmoid resection after firstepisode of diverticulitis

Surgical treatment in summary