Diverticulitis

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  • 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.