Information about Sigmoid Diverticular Disease by Dr Dhaval Mangukiya.
Details of sigmoid diverticular disease, classification of diverticular disease, pathophysiology, diverticular disease, presenting sumptoms, physical findings, diagnostic tests etc.
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3. Introduction
Formation of colonic diverticula - responsible for the
development of diverticulosis.
When symptomatic - it becomes diverticular disease.
Associated with numerous abdominal symptoms (Pain,
bloating, nausea, diarrhea and constipation).
Telling WHM. Discussion on diverticulitis. Proc R Soc Med 1920; 13: 55-64
4. Introduction
Common inWestern and industrialized countries
Diverticular disease - first described in the early 20th Century
Prevalence - increased
5%-10% in 1930
35%-50% in 1969 as per autopsy series
Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. Br Med J 1971; 2:450-454
6. Classification
of diverticular
disease
Classification for diverticulitis with perforation – first described by Hughes et al
Hughes ESR, Cuthbertson AM, Carden ABG. The surgical management of acute diverticulitis. Med J Aust 1963;1: 780–782.
7. Pathophysiology
Diverticula formation - high intraluminal pressures
As high as 90 mm Hg during peak contraction
Fiber-deficient diet - change in the colonic microflora -increase
in pathogenic bacteria
Reduced immune response of the host
Decreased bacterial production of short chain fatty acids
Degradation of soluble fibre.
Permit chronic inflammation and epithelial cell proliferation
Tursi A, Brandimarte G, Elisei W, Inchingolo CD, Aiello F. Epithelial cell proliferation of the colonic mucosa in different degrees of colonic diverticular disease. J Clin Gastroenterol 2006; 40: 306-311
8. Diverticular
Disease
Simmang CL, Shires III GT. Diverticular disease of the colon. In: Feldman M, Friedman LS, Sleisinger MH, editors. Sleisinger & Fordtran’s gastrointestinal and liver disease. 7th ed. Philadephia: Saunders, 2002:2100-2.
9. Presenting
Symptoms
Left lower quadrant abdominal pain
Radiation to back, ipsilateral flank, groin and even down the leg
Episodes of constipation or diarrhea
Secondary ileus with abdominal distention
Dysuria or urgency - possible bladder involvement
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins;
1998:384–393.
10. Presenting
Symptoms
Pneumaturia, fecaluria, or gas and stool through the vagina
Colovesical or colovaginal fistula
Fever - proportional to inflammatory response
High fever - perforation with abscess or peritonitis
Fournier’s gangrene - Rare
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins;
1998:384–393.
11. Physical
Findings
Tender to palpation - left lower quadrant and left iliac region
Rigidity/guarding – on deeper palpation
A positive psoas sign and/or obturator sign
Reflect retroperitoneal and/or pelvic involvement of the inflammatory
process
Gross perforation with peritonitis – tenderness spread to
abdomen
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins;
1998:384–393.
12. Diagnostic
Tests
Endoscopy -
With extreme caution - risk of gross perforation
Provide important information
May change acute management in <1% of cases
If no urgent indication - should be delayed until resolution
acute episode
Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504–507.
13. Diagnostic
Tests
Abdominal X-rays -
Plain films of the abdomen
Supine and upright/left lateral decubitus
To rule out pneumoperitoneum
To assess for obstruction.
Rarely used now
Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504–507.
14. Diagnostic
Tests
CT scan - preferred imaging study
Also if clinical suspicion of an abscess or other complicating
feature
Used in a limited manner to evaluate the anatomy of the colon
Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123–1129.
16. Diagnostic
Tests
CT scan -
Document diverticulitis, even if uncomplicated
Recognize and stratify patients according to the severity
Distinguish uncomplicated from complicated disease
Early CT-guided drainage of abscesses – down staging of complicated
diverticulitis
Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123–1129.
17. Diagnostic
Tests
Ultrasonography -
Transrectal ultrasound (TRUS) - evaluate diverticular disease in
conjunction with transabdominal ultrasound (TAUS)
CombiningTRUS withTAUS -
Reveals complications not visualized onTAUS alone
TRUS -
Accurate adjunct for confirming clinically suspected acute colonic
diverticulitis
Hollerweger A, Rettenbacher T, Macheiner P, et al. Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography. AJR Am J Roentgenol 2000;175: 1155–1160.
18. Diagnostic
Tests
Avoid false-negative results
Defines the severity of disease - better thanTAUS alone.
TRUS - useful adjunct in selected cases of recto sigmoid
diverticulitis
Hollerweger A, Rettenbacher T, Macheiner P, et al. Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography. AJR Am J Roentgenol 2000;175: 1155–1160.
19. Diagnostic
Tests
Magnetic Resonance Imaging (MRI) -
MRI Colonography - high correlation with CT findings in diverticular
disease
No exposure to ionizing radiation.
Three-dimensional rendered models and virtual colonoscopy - only in
the nonacute setting.
Schreyer AG, Furst A, Agha A, et al. Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis 2004;19: 474–480.
20. Management
Medical therapy:
The main objectives -
To improve symptoms
To resolve any infection or consequences of inflammation
To prevent recurrence of symptoms
Limiting serious complications
Surgical approach:
For treating acute, recurrent diverticulitis
Two or more prior episodes
Aydin HN, Remzi FH. Diverticulitis: when and how to operate? Dig Liver Dis 2004; 36: 435-445
21. Management
Dietary Fiber:
Increasing dietary fibre
To increase stool weight
Increase transit time
Lower intracolonic pressure
More insoluble fibre, especially whole wheat cereals, breads.
Commercially available fibre supplements
Gear JSS, Ware A, Fursdon, et al. Symptomless diverticular disease and intake of dietary fibre. Lancet 1979;1:511-4.
23. Current antibiotic
therapy in acute
diverticulitis
Chow AW. Appendicitis and diverticulitis. In: Hoeprich PD, Jordan MC, Ronald AR, editors. Infectious diseases: A treatise of infectious processes. Philadelphia: JB Lippincott, 1994: 878-881
24. Management
5-ASA:
Primary therapy - induction and maintenance of remission
Acts topically on the colonic mucosa to reduce inflammation
Newer non-sulphur-containing therapies – preferred
(eg. mesalazine)
Improved side-effect profiles
Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5: V1-V16
25. Management
Probiotics:
Bacteria Bifidobacterium spp., Lactobacillus spp. and certain
strains of E. Coli and budding yeast Saccharomyces cerevisiae
Causes –
Inhibition of pathogen adherence
Stimulation of immunoglobulinA secretion in Peyer’s patches
Enhancement of immune system activity
Controls balance of pro- and anti-inflammatory cytokines
Gionchetti P, Amadini C, Rizzello F, Venturi A, Palmonari V, Morselli C, Romagnoli R, Campieri M. Probiotics--role in inflammatory bowel disease. Dig Liver Dis 2002; 34 Suppl 2: S58-S62
26. Management
Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5: V1-V16
27. Management
Surgery:
Not recommended for first episode of uncomplicated Diverticulitis
If recurrence - elective resection considered after the second attack.
Also, if frank peritonitis/complications
Faynsod M, Stamos MJ, Arnell T, et al. A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surgeon 2000;66:841-3.
28. Management
Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78-82.
31. Complications
Bleeding
Perforation
Abscess
Fistula
Stricture
Obstruction
Ureteral Obstruction
Phlegmon (Inflammatory mass)
Saint’sTriad (Diverticulosis, cholelithiasis and hiatal hernia)
Boles RS, Jordan SM. The clinical significance of diverticulosis. Gastroenterology 1958;35:579–581.
32. Summary
The management of diverticulitis - undergone meaningful
change including antibiotics and surgery.
Ongoing investigations into medical therapies decrease
symptoms and reduce recurrences.
Areas that should be priorities for future research:
Identifying patients who will benefit from antibiotics and those in
whom it can safely be withheld.
Evaluating medical therapies, such as anti-inflammatories, antibiotics
or probiotics, and dietary interventions
Identifying risk factors for recurrent diverticulitis
Quantifying the yield, risks and timing of colonoscopy after an episode
of acute diverticulitis.
Strate L, Peery A, Neumann I, et al. American Gastroenterological Association technical review on the management of acute diverticulitis. Gastroenterology 2015;(In press).
Telling WHM. Discussion on diverticulitis. Proc R Soc Med 1920; 13: 55-64
Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. Br Med J 1971; 2:450-454
Morganstern L, Weiner R, Michel SL. “Malignant” diverticulitis. A clinical entity. Arch Surg 1979;114:1112–1126.
Hughes ESR, Cuthbertson AM, Carden ABG. The surgical management of acute diverticulitis. Med J Aust 1963;1: 780–782.
Tursi A, Brandimarte G, Elisei W, Inchingolo CD, Aiello F. Epithelial cell proliferation of the colonic mucosa in different degrees of colonic diverticular disease. J Clin Gastroenterol 2006; 40: 306-311
Simmang CL, Shires III GT. Diverticular disease of the colon. In: Feldman M, Friedman LS, Sleisinger MH, editors. Sleisinger & Fordtran’s gastrointestinal and liver disease. 7th ed. Philadephia: Saunders, 2002:2100-2.
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins; 1998:384–393.
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins; 1998:384–393.
Polk HC, Tuckson WB, Miller FB. The atypical presentations of diverticulitis. In: Welch JP, Cohen JL, Sardella WV, Vignati PV, eds. Diverticular Disease, Management of the Difficult Surgical Case. Baltimore: Williams & Wilkins; 1998:384–393.
Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504–507.
Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504–507.
Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123–1129.
Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123–1129.
Hollerweger A, Rettenbacher T, Macheiner P, et al. Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography. AJR Am J Roentgenol 2000;175: 1155–1160.
Hollerweger A, Rettenbacher T, Macheiner P, et al. Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography. AJR Am J Roentgenol 2000;175: 1155–1160.
Schreyer AG, Furst A, Agha A, et al. Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis 2004;19: 474–480.
Aydin HN, Remzi FH. Diverticulitis: when and how to operate? Dig Liver Dis 2004; 36: 435-445
Gear JSS, Ware A, Fursdon, et al. Symptomless diverticular disease and intake of dietary fibre. Lancet 1979;1:511-4.
Aldoori W, Ryan-Harshman M. Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician 2002; 48: 1632-1637
Chow AW. Appendicitis and diverticulitis. In: Hoeprich PD, Jordan MC, Ronald AR, editors. Infectious diseases: A treatise of infectious processes. Philadelphia: JB Lippincott, 1994: 878-881
Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5: V1-V16
Gionchetti P, Amadini C, Rizzello F, Venturi A, Palmonari V, Morselli C, Romagnoli R, Campieri M. Probiotics--role in inflammatory bowel disease. Dig Liver Dis 2002; 34 Suppl 2: S58-S62
Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53 Suppl 5: V1-V16
Faynsod M, Stamos MJ, Arnell T, et al. A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surgeon 2000;66:841-3.
Jensen DM, Machicado GA, Jutabha R, et al. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 2000;342:78-82.
AGA Institute Clinical Practice Guideline Development Process:http://www.gastro.org/practice/medical-position-statements/aga-institute-clinical-practice-guideline-development-process, accessed March 29, 2015.
AGA Institute Clinical Practice Guideline Development Process:http://www.gastro.org/practice/medical-position-statements/aga-institute-clinical-practice-guideline-development-process, accessed March 29, 2015.
Boles RS, Jordan SM. The clinical significance of diverticulosis. Gastroenterology 1958;35:579–581.
Strate L, Peery A, Neumann I, et al. American Gastroenterological Association technical review on the management of acute diverticulitis. Gastroenterology 2015;(In press).