DIVERTICULITISWhat Is It &What Happens If I Get It?Paul E. Pacheco, MDColon & Rectal Surgeon,Springfield Clinic
www.SpringfieldClinic.com
Who am I?• Colon & Rectal Surgeon– Medical School (“MD”)– General Surgeon• Additional Specialty Training– Surgical & Nonsu...
Springfield Clinic Colon & RectalSurgery
Gastrointestinal Tract
THE COLON, RECTUM, & ANUS
Anal Canal
What Does a CR Surgeon Do?• Screening & Therapeutic Colonoscopy• Cancer of the Colon, Rectum, Anus• Rectal Prolapse• Hemor...
diverticuL-OSIS
Diverticu-LOSIS at Colonoscopy
diverticuL-ITISwww.webmd.com
How Will I Know?• Steady left lower quadrant pain– May radiate to suprapubic region, back, or left groin• Commonly persist...
Why Does This Happen?• Hypothesis• “Pulsion” diverticulum– Increased pressure inside the colon– Weakening of the wall
Straining?
Eat Your Fiber!• Low Incidence of Diverticular Disease inAfrica– African dietary fiber intake• 60 -150g/day– European• 15 ...
But I’m Not Constipated Doc?• Fiber increases stool volume which leads towider colonic diameter– Wider Diameter = Lower Pr...
3.4 Grams / TBSPhttp://www.mosamuse.com/fill-all-5-cups-to-the-brim/cup-of-waterhttp://www.metamucilweightlosstips.com/
Other Risk Factors• High Fat• Possibly Red Meat– (heme is toxic to rat colons)• NSAIDS ?– Damage to the inner lining of th...
Other Thoughts• Physical Activity• Age and Declining colonic wall MechanicalStrength
How Common is This?• 5% in the 1900s  50% today• 5% by age 40• 80% by age 80!
Will I Need Surgery?• 10-20% develop symptoms– 10-20% hospitalization– 20-50% require surgery– 5% have significant bleedin...
Variations• Uncomplicated Diverticulitis – Outpatient Tx• Complicated Diverticulitis– Abscess– Purulent Peritonitis– Fecul...
Uncomplicated Diverticulitis
“Uncomplicated” Diverticulitis• Mild Case– Afebrile or low fevers, normal or mild leukocytosis,absence of emesis, able to ...
More Severe “Uncomplicated”• Fevers, chills, leukocytosis, emesis,nausea, significant pain• Inpatient treatment• Broad-spe...
Complicated Disease• Often identified by either significant clinicalpicture or CT scan– Abscess– Purulent Peritonitis– Fec...
Abscess• Hinchey Classification– Stage I: Pericolic or Mesenteric Abscess– Stage II: Walled-off Pelvic Abscess– Stage III:...
Stage I: Inflammation of and Next to the Colon• Mesenteric Abscess
Stage II: “Pus Pocket” in the Abdomen
Stage III: Pus throughout the abdomen• Abscess
Stage IV: Feces throughout the abdomen
What do you want ME to do about it?• Options?– Bowel rest (NPO)– Antibiotics by mouth at home– Antibiotics by IV in the ho...
Well who gets what?• Depends– Severity of Disease– Clinical Judgment– Availability Surgeon– Availability of an Interventio...
Treatment– Stage I most often successfully managed byyour PCP– Consultation to a Gastroenterologist or Colon& Rectal Surge...
COLONOSCOPY!!!http://www.absoluteastronomy.com/topics/Polypectomyhttp://www.webmd.com/digestive-• AGE 50, Everybody!!!• 10...
I’m not getting better doc!• Failure to improve after 3-5 days ofadequate medical management  CTscan• Smoldering Divertic...
IR Drain?• Fairly recently all patients with aperforation seen on CT scan hademergency surgery• Image Guided Percutaneous ...
What if I get better without surgery?• Recurrent disease is less common than previouslythought.– Traditionally reported re...
American Society of Colon and RectalSurgeons• The exact indications for surgery in recurrentdiverticular disease remain un...
What Factors Does YourSurgeon Consider• Decisions should be based on– Clinical Picture• How many “bouts” CT documentation?...
What If I Need EmergencySurgery?http://amsproject-jennifer.blogspot.com/2007/10/sigmoid-colon-resection-and-colostomy.html
Emergency “Open” Surgeryhttp://www.coloncancer.lv/mape/content2.htm
Will I have a “bag” forever?http://powderpostbeetle.pixnet.net/blogSigmoid ColonDiverticulitis
Laparoscopic“Minimally Invasive”http://www.bristolsurgery.com/page.aspx?id=91 AND http://www.productomedico.com/productos/...
Laparoscopic“Minimally Invasive”http://www.websurg.com/doi-vd01en1382e.htmhttp://www.ecbloguer.com/hablemosdefertilidad/
Advantages of MinimallyInvasive Surgery• Smaller Incisions• Better cosmesis• Less Pain  Less Narcotics• Faster return of ...
http://www.surgeryobesity.org/laparoscopy.htmlOpen Vs. Laparoscopic
Robotic Surgery?http://citizensmedicalcenter.org/robotic-surgery/
SO I HATE FIBER, Now What?http://seanandnicolehuddleston.blogspot.com/2010_05_01_archive.html
Thank You!
Fiber and your DietAmanda B Figge, MS, RD, LDNDietetics and Nutrition
Fiber and You• Why fiber is lacking in our diets.• How much fiber do we need?• How do I increase my fiber intake?• Special...
Typical WesternDiet• Processed Foods• Very low in Fruits and Vegetables• Low in Plant-based food choices• Low in Fiber
Food Portion Size FiberBreakfastEggs 2 large 0 gmBacon 2 slices 0 gmWhite Toast 2 slices 1 gmButter 1 Tbsp 0 gmJelly 2 Tbs...
“Healthy” Diet
Food Portion Size FiberBreakfastGreek yogurt 1 cup 0 gmBlueberries ¼ cup 0.9 gmStrawberries ¼ cup 0.8 gmLunchSpinach salad...
Fiber Facts• Average fiber intake for Americans:– 15 grams• % of people meeting fiberrecommendations:– 5%• Adequate Fiber ...
Why are people falling short onfiber intake?
Fiber Content of FruitsFruit ServingSizeFiberRaspberries1 cup 8.0 gmPear +skin1 medium 5.5 gmApple +skin1 medium 4.4 gmBlu...
Fiber Content of VegetablesVegetable ServingSizeFiberPeas,cooked1 cup 8.8 gmBroccoli,boiled1 cup 5.1 gmTurnipgreens1 cup 5...
Fiber Content ofGrainsGrains ServingSizeFiberFiber OneCereal½ cup 14 gmPasta,wholewheat,cooked1 cup 6.2 gmBarley,cooked1 c...
Looking for Whole Grains
Fiber Content ofBeans/Legumes/NutsFood ServingSizeFiberLentils,cooked1 cup 16.3 gmBlack Beans 1 cup 15.0 gmGarbanzoBeans1 ...
Benefits of Fiber• Improve satiety• Weight management• Blood sugar control• Reduce cholesterol levels• Promote digestive h...
DiverticulitisWhat to do during a flare-up???
ANSWERS• If diarrhea/bleeding, limit solid food intake• Low-Fiber Diet– Lessens the frequency and volume of stools– Allows...
Recommended Foods during aflare-upGrains• Refined WHITEproducts• Cream of Wheat• Grits• White bread, pasta,riceDairy• Milk...
Recommended Foods during aflare-upMeat/Proteins• Eggs• Tender, well-cooked chicken,pork, beef, fish• SMOOTH nutbutters• To...
Recommended Foods during aflare-upFruits• Canned, cooked,soft fruits– Applesauce• Fruit juice withoutpulpVegetables• Canne...
Foods NOT Recommended duringa flare-up• Tough meat or meat with gristle• Fried foods• Beans• Yogurt with added fruit• Nuts...
Foods NOT Recommended duringa flare-up• RAW Fruits and Vegetables– Cooked greens or spinach– Peas and corn– Dried fruit– F...
Nutrition Therapy forDiverticulosis• High Fiber– 6-10 grams higher than normalrecommendations (25-35 grams/day)– Add gradu...
Tips for Adding Fiber• Start the day off with a high-fiber or brancereal.• Add fresh fruit to yogurt.• Add beans to salads...
Special Dietary Concerns• Crohn’s Disease or Ulcerative Colitis• Celiac Disease• Recent Intestinal surgery• New Colostomy/...
SUMMARY• Aim for 5 servings offruits &vegetables/day• Choose whole grains• Increaseconsumption ofplant-based foods• Supple...
Thank You!Any Questions?
A Disease Caused by Diet: Diverticulitis
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A Disease Caused by Diet: Diverticulitis

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We all know fiber is important to a healthy diet, but do you know why? One reason is the prevention of diverticulosis and diverticulitis, an inflammation of the large bowel. Please join Dr. Paul Pacheco discusses the prevention and treatment of this painful condition that requires surgery in some instances. Special Guest: Amanda Figge, MS, RD, LDN, Registered Dietitian with Springfield Clinic’s Dietetics & Nutrition Department

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  • This is a group of exceptional individuals … Why become a colon and rectal surgeon.
  • Common symptoms that people experience when they are having a “attack” of diverticulitis include lower abdominal pain, fevers, chills, “constipation,” rectal discomfort, sensation that you need to have a bowel movement but can’t pass a bowel movement, lower back pain, difficulty or discomfort with urination.
  • Metamucil 3.4 grams per tablespoon.
  • Drink more water
  • A Disease Caused by Diet: Diverticulitis

    1. 1. DIVERTICULITISWhat Is It &What Happens If I Get It?Paul E. Pacheco, MDColon & Rectal Surgeon,Springfield Clinic
    2. 2. www.SpringfieldClinic.com
    3. 3. Who am I?• Colon & Rectal Surgeon– Medical School (“MD”)– General Surgeon• Additional Specialty Training– Surgical & Nonsurgical Management ofDiseases of the Colon, Rectum, Anus• Fellowship/Residency Training
    4. 4. Springfield Clinic Colon & RectalSurgery
    5. 5. Gastrointestinal Tract
    6. 6. THE COLON, RECTUM, & ANUS
    7. 7. Anal Canal
    8. 8. What Does a CR Surgeon Do?• Screening & Therapeutic Colonoscopy• Cancer of the Colon, Rectum, Anus• Rectal Prolapse• Hemorrhoids & GI Bleeding• Anorectal Abscesses & Fistulas• Ulcerative Colitis & Crohn’s Dz• Fecal Incontinence• Diverticulitis
    9. 9. diverticuL-OSIS
    10. 10. Diverticu-LOSIS at Colonoscopy
    11. 11. diverticuL-ITISwww.webmd.com
    12. 12. How Will I Know?• Steady left lower quadrant pain– May radiate to suprapubic region, back, or left groin• Commonly persists for several days– May disappear entirely until further exacerbation• Alteration in bowel habit– Constipation vs diarrhea• Anorexia, nausea, vomiting, fever,• possible dysuria, urgency and frequency
    13. 13. Why Does This Happen?• Hypothesis• “Pulsion” diverticulum– Increased pressure inside the colon– Weakening of the wall
    14. 14. Straining?
    15. 15. Eat Your Fiber!• Low Incidence of Diverticular Disease inAfrica– African dietary fiber intake• 60 -150g/day– European• 15 - 25g/day– Japanese• 20 g/day– USA• 13-20g/day
    16. 16. But I’m Not Constipated Doc?• Fiber increases stool volume which leads towider colonic diameter– Wider Diameter = Lower Pressure– Sigmoid Colon has a narrow diameter• Patients with diet high in fiber have a shortercolonic transit time• Swiftly passed stool through the sigmoid colonsubjects the colon to less straining• Provides short chain fatty acids• Lowers Cholesterol, good for anorectal disease
    17. 17. 3.4 Grams / TBSPhttp://www.mosamuse.com/fill-all-5-cups-to-the-brim/cup-of-waterhttp://www.metamucilweightlosstips.com/
    18. 18. Other Risk Factors• High Fat• Possibly Red Meat– (heme is toxic to rat colons)• NSAIDS ?– Damage to the inner lining of the colon– Lined to higher rates of diverticular disease• Alcohol - 2X the risk• Smoking – 3X the risk of developingcomplications (in some studies)
    19. 19. Other Thoughts• Physical Activity• Age and Declining colonic wall MechanicalStrength
    20. 20. How Common is This?• 5% in the 1900s  50% today• 5% by age 40• 80% by age 80!
    21. 21. Will I Need Surgery?• 10-20% develop symptoms– 10-20% hospitalization– 20-50% require surgery– 5% have significant bleeding• LESS THAN 1% OF THOSE WITHDIVERTICULOSIS REQUIRE SURGERY
    22. 22. Variations• Uncomplicated Diverticulitis – Outpatient Tx• Complicated Diverticulitis– Abscess– Purulent Peritonitis– Feculent Peritonitis– Fistula• Enteric, vesicle, cutaneous, etc.– Hemorrhage– Liver Abscess– Obstruction
    23. 23. Uncomplicated Diverticulitis
    24. 24. “Uncomplicated” Diverticulitis• Mild Case– Afebrile or low fevers, normal or mild leukocytosis,absence of emesis, able to tolerate liquids, painmanageable antibiotics by mouth– Clear liquid/low residue diet– Resume diet when symptoms subside– CT not necessary• Helps to document diagnosis
    25. 25. More Severe “Uncomplicated”• Fevers, chills, leukocytosis, emesis,nausea, significant pain• Inpatient treatment• Broad-spectrum antibiotics• NPO/IVF• Serial exams• CT likely to be helpful– Rule out complicated disease
    26. 26. Complicated Disease• Often identified by either significant clinicalpicture or CT scan– Abscess– Purulent Peritonitis– Feculent Peritonitis– Fistula• Enteric, vesicle, cutaneous, etc.– Hemorrhage– Hepatic Abscess– Obstruction
    27. 27. Abscess• Hinchey Classification– Stage I: Pericolic or Mesenteric Abscess– Stage II: Walled-off Pelvic Abscess– Stage III: Generalized Purulent Peritonitis– Stage IV: Generalized Fecal Peritonitis
    28. 28. Stage I: Inflammation of and Next to the Colon• Mesenteric Abscess
    29. 29. Stage II: “Pus Pocket” in the Abdomen
    30. 30. Stage III: Pus throughout the abdomen• Abscess
    31. 31. Stage IV: Feces throughout the abdomen
    32. 32. What do you want ME to do about it?• Options?– Bowel rest (NPO)– Antibiotics by mouth at home– Antibiotics by IV in the hospital– Image Guided Drainage– Surgery• Washout• Diversion Only• Resection and Diversion• Resection and Anastomosis
    33. 33. Well who gets what?• Depends– Severity of Disease– Clinical Judgment– Availability Surgeon– Availability of an Interventional Radiologist
    34. 34. Treatment– Stage I most often successfully managed byyour PCP– Consultation to a Gastroenterologist or Colon& Rectal Surgeon for COLONOSCOPY• Confirm diagnosis• Rule out malignancy
    35. 35. COLONOSCOPY!!!http://www.absoluteastronomy.com/topics/Polypectomyhttp://www.webmd.com/digestive-• AGE 50, Everybody!!!• 10 years Earlier thanFamily Member withCancer
    36. 36. I’m not getting better doc!• Failure to improve after 3-5 days ofadequate medical management  CTscan• Smoldering Diverticulitis• “Complicated” Diverticulitis– Fistulous connection– Large Pelvic Abscess– Liver Abscess– Obstruction, “Malignant Diverticulitis”
    37. 37. IR Drain?• Fairly recently all patients with aperforation seen on CT scan hademergency surgery• Image Guided Percutaneous Drainage– Revolutionized the way Diverticulitis isManaged Today• Convert emergent situation into elective
    38. 38. What if I get better without surgery?• Recurrent disease is less common than previouslythought.– Traditionally reported recurrence rates after an uncomplicatedinitial episode - 30-50%.– Newer data suggests that the recurrence rate is lower varyingfrom 5-20%– Recurrences tending to mimic the severity of the initial attack– In patients requiring urgent surgery it is the initial attack in over80% of cases.• Argument in favor of surgical therapy in cases ofrecurrent disease, which is recurrence is inevitable andthat subsequent attacks may be more complicated,being questioned.
    39. 39. American Society of Colon and RectalSurgeons• The exact indications for surgery in recurrentdiverticular disease remain under discussion– but the trend seems to be more in favor of non-operative therapy– and individualizing surgery for this particularindication.• “Case By Case Basis”– Discussion with your PCP and/or Surgeon
    40. 40. What Factors Does YourSurgeon Consider• Decisions should be based on– Clinical Picture• How many “bouts” CT documentation?– How often?• How Severe, chronic pain, obstruction?– Complications?• Fistulas, Large Abscess? Drained?• obstruction• Inability to rule out Cancer?– Other Medical Problems
    41. 41. What If I Need EmergencySurgery?http://amsproject-jennifer.blogspot.com/2007/10/sigmoid-colon-resection-and-colostomy.html
    42. 42. Emergency “Open” Surgeryhttp://www.coloncancer.lv/mape/content2.htm
    43. 43. Will I have a “bag” forever?http://powderpostbeetle.pixnet.net/blogSigmoid ColonDiverticulitis
    44. 44. Laparoscopic“Minimally Invasive”http://www.bristolsurgery.com/page.aspx?id=91 AND http://www.productomedico.com/productos/gelport-sistema-mano-asistida-para-laparoscopia
    45. 45. Laparoscopic“Minimally Invasive”http://www.websurg.com/doi-vd01en1382e.htmhttp://www.ecbloguer.com/hablemosdefertilidad/
    46. 46. Advantages of MinimallyInvasive Surgery• Smaller Incisions• Better cosmesis• Less Pain  Less Narcotics• Faster return of bowel function• Faster healing and return to Activities• Faster recovery of lung function• Shorter hospital stay (1-6 days)
    47. 47. http://www.surgeryobesity.org/laparoscopy.htmlOpen Vs. Laparoscopic
    48. 48. Robotic Surgery?http://citizensmedicalcenter.org/robotic-surgery/
    49. 49. SO I HATE FIBER, Now What?http://seanandnicolehuddleston.blogspot.com/2010_05_01_archive.html
    50. 50. Thank You!
    51. 51. Fiber and your DietAmanda B Figge, MS, RD, LDNDietetics and Nutrition
    52. 52. Fiber and You• Why fiber is lacking in our diets.• How much fiber do we need?• How do I increase my fiber intake?• Special dietary concerns.
    53. 53. Typical WesternDiet• Processed Foods• Very low in Fruits and Vegetables• Low in Plant-based food choices• Low in Fiber
    54. 54. Food Portion Size FiberBreakfastEggs 2 large 0 gmBacon 2 slices 0 gmWhite Toast 2 slices 1 gmButter 1 Tbsp 0 gmJelly 2 Tbsp 0.4 gmLunchBig Mac 1 sandwich 3 gmFries Medium 5 gmCoke Large 0 gmDinnerSteak 6 oz 0 gmMashed Potatoes ¾ cup 2.4 gmMushrooms ¼ cup 0.7 gmZucchini ½ cup 1.3 gmTotal 13.4 gm
    55. 55. “Healthy” Diet
    56. 56. Food Portion Size FiberBreakfastGreek yogurt 1 cup 0 gmBlueberries ¼ cup 0.9 gmStrawberries ¼ cup 0.8 gmLunchSpinach salad 1 cup 0.7 gmGrilled Chicken 3 oz 0 gmStrawberries ½ cup 1.6 gmWalnuts ¼ cup 2 gmDinnerSalmon 5 oz 0 gmBroccoli 1 cup 5.1 gmWhite rice ¾ cup 0.5 gmTotal 11.6 gm
    57. 57. Fiber Facts• Average fiber intake for Americans:– 15 grams• % of people meeting fiberrecommendations:– 5%• Adequate Fiber intake is 14 grams/1000calories consumed:– Women = 25 grams/day– Men = 38 grams/day
    58. 58. Why are people falling short onfiber intake?
    59. 59. Fiber Content of FruitsFruit ServingSizeFiberRaspberries1 cup 8.0 gmPear +skin1 medium 5.5 gmApple +skin1 medium 4.4 gmBlueberries1 cup 3.6 gmBanana 1 medium 3.1 gmOrange 1 medium 3.1 gmStrawberries1 cup 3.0 gmPrunes 4 (0.2 oz) 2.0 gm
    60. 60. Fiber Content of VegetablesVegetable ServingSizeFiberPeas,cooked1 cup 8.8 gmBroccoli,boiled1 cup 5.1 gmTurnipgreens1 cup 5.0 gmSweet Corn 1 cup 4.2 gmBrusselsSprouts1 cup 4.1 gmOkra 1 cup 4.0 gmGreenbeans, fresh1 cup 4.0 gmCarrots 1 cup 3.6 gmPotato +skin1 small (30z)3.0 gm
    61. 61. Fiber Content ofGrainsGrains ServingSizeFiberFiber OneCereal½ cup 14 gmPasta,wholewheat,cooked1 cup 6.2 gmBarley,cooked1 cup 6.0 gmShreddedWheat1 cup 6.0 gmBranFlakes¾ cup 5.3 gmOatmeal 1 cup 4.0 gmQuinoa ¾ cup 3.9 gmBrownrice1 cup 3.5 gm
    62. 62. Looking for Whole Grains
    63. 63. Fiber Content ofBeans/Legumes/NutsFood ServingSizeFiberLentils,cooked1 cup 16.3 gmBlack Beans 1 cup 15.0 gmGarbanzoBeans1 cup 12.5 gmGreatNorthernBeans1 cup 12.4 gmSunflowerseeds¼ cup 3.9 gmAlmonds 1 oz (23nuts)3.5 gmPeanuts 1 oz 2.4 gmGroundFlaxseed1 Tbsp 2.0 gm
    64. 64. Benefits of Fiber• Improve satiety• Weight management• Blood sugar control• Reduce cholesterol levels• Promote digestive health
    65. 65. DiverticulitisWhat to do during a flare-up???
    66. 66. ANSWERS• If diarrhea/bleeding, limit solid food intake• Low-Fiber Diet– Lessens the frequency and volume of stools– Allows GI tract to rest so it can heal quicker– Eliminate food particles that could becometrappedin sacs causing bacterial contamination– Consume bland, easily digestible foods
    67. 67. Recommended Foods during aflare-upGrains• Refined WHITEproducts• Cream of Wheat• Grits• White bread, pasta,riceDairy• Milk• Yogurt• Mild cheese• Cottage cheese• Soy, Rice, Almondmilk• Sherbet
    68. 68. Recommended Foods during aflare-upMeat/Proteins• Eggs• Tender, well-cooked chicken,pork, beef, fish• SMOOTH nutbutters• TofuFats/Oils• Canola/Olive oils• Usebutter/margarinesparingly• Use cream cheese,mayonnaisesparingly
    69. 69. Recommended Foods during aflare-upFruits• Canned, cooked,soft fruits– Applesauce• Fruit juice withoutpulpVegetables• Canned, well-cooked vegetables• Mashed potatoes• Vegetables with outskins/seeds
    70. 70. Foods NOT Recommended duringa flare-up• Tough meat or meat with gristle• Fried foods• Beans• Yogurt with added fruit• Nuts/seeds• Whole wheat/whole grain products– Cereal, whole wheat bread, brown rice, wholewheat pasta
    71. 71. Foods NOT Recommended duringa flare-up• RAW Fruits and Vegetables– Cooked greens or spinach– Peas and corn– Dried fruit– Fruit with skins or seeds
    72. 72. Nutrition Therapy forDiverticulosis• High Fiber– 6-10 grams higher than normalrecommendations (25-35 grams/day)– Add gradually– Use of supplements if intake is inadequate• Some practitioners encourage therestriction of nuts, seeds, corn and popcorn.– Recent research indicates this may not benecessary
    73. 73. Tips for Adding Fiber• Start the day off with a high-fiber or brancereal.• Add fresh fruit to yogurt.• Add beans to salads, sauces, stews,casseroles.• Add grated vegetables to meatloaf, breads,casseroles, sauces.• Choose fresh fruit and vegetables over juice.• Add ground flaxseed to cereal, yogurt,applesauce.
    74. 74. Special Dietary Concerns• Crohn’s Disease or Ulcerative Colitis• Celiac Disease• Recent Intestinal surgery• New Colostomy/Ileostomy• Radiation Therapy to Pelvis or Lower Bowel
    75. 75. SUMMARY• Aim for 5 servings offruits &vegetables/day• Choose whole grains• Increaseconsumption ofplant-based foods• Supplement withfiber-fortified foodsor supplements, ifneeded
    76. 76. Thank You!Any Questions?

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