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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 …

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
  • Transcript

    • 1. DIVERTICULITISWhat Is It &What Happens If I Get It?Paul E. Pacheco, MDColon & Rectal Surgeon,Springfield Clinic
    • 2.
    • 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. Springfield Clinic Colon & RectalSurgery
    • 5. Gastrointestinal Tract
    • 7. Anal Canal
    • 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. diverticuL-OSIS
    • 10. Diverticu-LOSIS at Colonoscopy
    • 11.
    • 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. Why Does This Happen?• Hypothesis• “Pulsion” diverticulum– Increased pressure inside the colon– Weakening of the wall
    • 14. Straining?
    • 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. 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. 3.4 Grams / TBSP
    • 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. Other Thoughts• Physical Activity• Age and Declining colonic wall MechanicalStrength
    • 20. How Common is This?• 5% in the 1900s  50% today• 5% by age 40• 80% by age 80!
    • 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. Variations• Uncomplicated Diverticulitis – Outpatient Tx• Complicated Diverticulitis– Abscess– Purulent Peritonitis– Feculent Peritonitis– Fistula• Enteric, vesicle, cutaneous, etc.– Hemorrhage– Liver Abscess– Obstruction
    • 23. Uncomplicated Diverticulitis
    • 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. 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. 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. 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. Stage I: Inflammation of and Next to the Colon• Mesenteric Abscess
    • 29. Stage II: “Pus Pocket” in the Abdomen
    • 30. Stage III: Pus throughout the abdomen• Abscess
    • 31. Stage IV: Feces throughout the abdomen
    • 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. Well who gets what?• Depends– Severity of Disease– Clinical Judgment– Availability Surgeon– Availability of an Interventional Radiologist
    • 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. COLONOSCOPY!!!• AGE 50, Everybody!!!• 10 years Earlier thanFamily Member withCancer
    • 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. 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. 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. 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. 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. What If I Need EmergencySurgery?
    • 42. Emergency “Open” Surgery
    • 43. Will I have a “bag” forever? ColonDiverticulitis
    • 44. Laparoscopic“Minimally Invasive” AND
    • 45. Laparoscopic“Minimally Invasive”
    • 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. Vs. Laparoscopic
    • 48. Robotic Surgery?
    • 49. SO I HATE FIBER, Now What?
    • 50. Thank You!
    • 51. Fiber and your DietAmanda B Figge, MS, RD, LDNDietetics and Nutrition
    • 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. Typical WesternDiet• Processed Foods• Very low in Fruits and Vegetables• Low in Plant-based food choices• Low in Fiber
    • 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. “Healthy” Diet
    • 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. 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. Why are people falling short onfiber intake?
    • 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. 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. 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. Looking for Whole Grains
    • 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. Benefits of Fiber• Improve satiety• Weight management• Blood sugar control• Reduce cholesterol levels• Promote digestive health
    • 65. DiverticulitisWhat to do during a flare-up???
    • 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. 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. 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. Recommended Foods during aflare-upFruits• Canned, cooked,soft fruits– Applesauce• Fruit juice withoutpulpVegetables• Canned, well-cooked vegetables• Mashed potatoes• Vegetables with outskins/seeds
    • 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. 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. 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. 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. 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. SUMMARY• Aim for 5 servings offruits &vegetables/day• Choose whole grains• Increaseconsumption ofplant-based foods• Supplement withfiber-fortified foodsor supplements, ifneeded
    • 76. Thank You!Any Questions?