Your SlideShare is downloading. ×
Surgical Management of Colonic Diverticulitis
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Surgical Management of Colonic Diverticulitis

472
views

Published on

Published in: Health & Medicine

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
472
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
27
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Diverticulitis and Management issues Prakash K
  • 2. 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
  • 3. 299 pts out of 3022 colonoscopies 258 (85%) were incidental 40% right sided 46% Left colonic 13% pan colonic
  • 4. 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
  • 5. Effect of the Industrial Revolution  No pathologic specimens in European museums or case reports of diverticulitis or diverticulosis prior to Industrial Revolution (~1750-1850)
  • 6. 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 rollermilling and the first cases of diverticulitis
  • 7. 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)
  • 8. Etiology of Diverticulosis
  • 9. Diverticulitis 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 ▫ Fecalith becomes impacted in a diverticulum ▫ Erosion through the serosa  Perforation
  • 10. 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
  • 11. Definitions Diverticulum: saccular outpouching of the colonic wall. • Diverticulosis: presence of diverticuli without complications • Diverticulitis: presence of peridiverticular inflammation or infection • Complicated presentations: perforation, obstruction, stricture, fistula, or hemorrhage. • Phlegmon: not condsidered as complication
  • 12. Incidence Rare under 30 40% @ 60, 60% > 80 95% sigmoid and left colon Progressively more proximally in Asian countries 10-25% develop diverticulitis
  • 13. 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
  • 14. 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 CT guidance – Assess extraluminal findings
  • 15. 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.
  • 16. Classification systems • • Ambrosetti • • Modified Hinchey
  • 17. 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
  • 18. 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
  • 19. Controversies
  • 20. ASCRS Guidelines • “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.” Rafferty J, DCR 2006
  • 21. Practice Parameters • Elective resection after two documented attacks of diverticulitis • Complicated diverticulitis: resection after the first attack • Patients below 40, after first attack
  • 22. Stage 0  Generally treated with Oral antibiotics  Ciprofloxacin+metronid azole  Cephalosporins+metro  Low residue diet initially  High fiber diet once symptoms resolve  Interval colonoscopy
  • 23. Stage Ia
  • 24. 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
  • 25. Stage Ib or II Complicated 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)
  • 26. Stage III and IV Complicated Diverticulitis • Can be difficult to distinguish on CT Scan or clinically • Generalized or Localized Peritonitis • Sepsis • Fever • Elevated WBC
  • 27. 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
  • 28. 1. 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?
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. Nuts • 2.5g fiber per 1 oz • Vitamin E • ↓CRP and IL-6 levels • Rich in Zinc and Magnesium • Anti-inflammatory properties popcorn • 3.6g fiber per 3cup • Lutein – micronutrient with anti-inflammatory and chemoproctective properties
  • 33. Can we eat Seeds, Nuts and Popcorn? Yes!
  • 34. Do all young patients (age < 50) require sigmoid colon resection?
  • 35. 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
  • 36. 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
  • 37. 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
  • 38. 5.In the immunocompromised Increased likelihood of free perforation and fecal peritonitis • Clinical presentation often underestimates the severity • Very large percentage will fail standard, nonoperative treatment • Most require urgent surgical intervention, associated with a higher mortality rate – 39 vs 2% in noncompromised patients • American society of colon and rectal surgeons recommend elective sigmoid resection after first episode of diverticulitis
  • 39. Surgical treatment in summary