Uploaded on


More in: Education
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads


Total Views
On Slideshare
From Embeds
Number of Embeds



Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

    No notes for slide


  • 1. Diverticular Disease www.hi-dentfinishingschool.blogspot.com
  • 2.  
  • 3. Overview
    • A diverticulum is an abnormal sac or pouch protruding from the wall of a hollow organ.
      • Diverticula ; pouches
      • Diverticulosis ; condition of having diverticula
    • Diverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution.
      • Decreased consumption of unprocessed cereals along with the increased consumption of sugar and meat
    • The formation of diverticula is also related to aging
      • Rare in individuals younger than the age of 30 years, but at least two thirds of Americans will have developed colonic diverticula by the age of 80.
  • 4. Pathogenesis
    • Diverticula are actually herniations of mucosa through the colon at sites of penetration of the muscular wall by arterioles
      • On the mesenteric side of the antimesenteric teniae
    • Sigmoid colon
      • The most common site (50%)
      • The smallest luminal diameter.
      • Low fiber diet -> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall
  • 5. Diverticular bleeding
    • The most common cause of hematochezia in patients over the age of 60
      • 20% of patients with diverticulosis will have GI bleeding.
    • Risk factor ; HT, Artherosclerosis, NSAID
    • Usually self limited, but rebleeding risk (25%)
    • Localization ; Colonoscopy, Angiography
    • Surgery
      • Unstable hemodynamics, 6-unit bleed within 24 hr
      • Without localization ; Total colectomy
  • 6. Diverticulitis
    • Definition
      • Inflammation of a diverticulum, is related to the retention of particulate material within the diverticular sac and the formation of a fecalith
      • Actually an extraluminal pericolic infection caused by the extravasation of feces through the perforated diverticulum
    • Presentation
      • LLQ pain : may radiate to the suprapubic, groin, back
      • Bowel habit change, Anorexia, Fever, Chill, Urinary urgency
  • 7. Diverticulitis
    • Physical Findings
      • Dependent on the site of perforation, the amount of contamination , and the presence or absence of secondary infection of adjacent organs
      • Tenderness, Muscle guarding
      • Tender mass : phlegmon or abscess
      • Abdominal distension : ileus or obstruction
      • Tender fluctuant pelvic mass on rectal or vaginal exam
  • 8. Diverticulitis
    • Diagnostic Tests
      • CT
        • The preferred test to confirm the suspected diagnosis
        • Location of infection, extent of inflammatory process, presence and location of an abscess, secondary complications
        • sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ± the collection of contrast material or fluid
      • MRI, US
      • Water soluble contrast enema
        • Distinguish acute diverticulitis from perforated cancer
        • Risk of increasing the colonic pressure, extravasation of feces through the perforated diverticulitis
  • 9. Uncomplicated Diverticulitis
    • Disease not associated with free intraperitoneal perforation, fistula formation, or obstruction
    • Nonoperative treatment
      • Bowel rest + Antibiotics ; 75% response
      • Trimethoprim/sulfamethoxazole or ciprofloxacin and metronidazole ; aerobic gram-negative rods and anaerobic bacteria
      • The addition of ampicillin to this regimen for nonresponders ; enterococci
      • Single-agent therapy ; a third-generation penicillin such as piperacillin
      • The usual course of antibiotics is 7 to 10 days
  • 10. Uncomplicated Diverticulitis
    • Investigative studies
      • After the symptoms have subsided for at least 3 weeks
      • To establish the presence of diverticula and to exclude cancer, which can mimic diverticulitis
      • Colonoscopy > Barium enema
    • Recurrent disease
      • Second attack (<25%) -> Third attack (>50%)
      • Elective resection
        • After infection control ; usually 4 to 6 weeks after the episode
        • Laparoscopic resection ; growing trend
        • Immunocompromised patient : after single attack
  • 11. Complicated Diverticulitis
    • Hinchey classification
      • Stage I: Pericolic or mesenteric abscess
      • Stage II: Walled-off pelvic abscess
      • Stage III: Generalized purulent peritonitis
      • Stage IV: Generalized fecal peritonitis
  • 12. Complicated Diverticulitis Abscess
    • Usually confined to the pelvis
    • Significant pain, fever, and leukocytosis
    • More than 2cm ; should be drained
      • Percutaneous or transanal > laparotomy
    • Elective surgery ; after 6weeks following drainage
      • Complete removal of the entire abnormally thickened bowel
  • 13. Complicated Diverticulitis Fistula
    • Skin, bladder, vagina, or small bowel
    • Sigmoid-vesical fistula
      • Pneumaturia, fecaluria, and recurrent UTI (Urosepsis)
      • CT ; may demonstrate air in the bladder
      • Barium enema, IVP, Cystoscopy
    • Treatment
      • Initial treatment ; infection control and reduce the associated inflammation
      • Rarely a cause for emergency surgery
      • Diagnostic steps such as coloscopy should be taken to confirm the cause of the fistula before a definitive operation is undertaken.
  • 14. Generalized Peritonitis
    • Mechanism
      • Perforation without sealing by the body’s normal defenses -> contaminated with feces
      • Abscess burst into the unprotected peritoneal cavity -> contaminated with enteric bacteria
    • Immediate operative intervention
      • Excise the segment of colon containing perforation and construct a colostomy using noninflammed colon
      • Peritoneal cavity irrigation, iv antibiotics
    • Colostomy repair
      • Usually after a period of at least 10 weeks
  • 15. Diverticulosis in Korea
    • Characteristics
      • Low incidence, but increasing
      • Rt colon (over 60%) > Lt colon
      • Young Age, Man, Congenital, Solitary, True type, Uncomplicated type
    • Differential Diagnosis from Acute Appendicitis
      • RLQ pain ; first symptom site, long duration
      • Nausea, vomiting ; absent or low
      • Previous appendectomy
      • Known diverticulosis (Barium enema, Colonoscopy)
      • Fecalith
      • Age ; 30~40 year old (later than appendicitis)
      • History of lower GI bleeding
  • 16. References
    • Sabiston Textbook of Surgery 17ed
    • Harrison’s Principles of Internal Medicine 16th
    • Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current management of diverticulitis. Curr Surg . 2004 Jul-Aug;61(4):361-5
    • Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg . 2004 Dec;199(6):904-12.
    • Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate? Surgery . 2004 Oct;136(4):725-30.
    • Park JK et al. Clinical analysis of right colon diverticulitis. J Korean Surg Soc 2003 Jan;64:44-48
    • Chang JH et al. Surgical treatment of the colonic diverticulosis. J Korean Surg Soc 2002 May;62:415-420
  • 17. Thank you for your attentions.