Management of Diverticular bleeding

1. Diverticular Diseases

2. • Diverticulosis is a condition that develops when
pouches form in the wall of the colon.
• False and true
• The most known true is Meckel's
Meckel's diverticulum: The rule of 2's
• 2% of the population.
• 2 feet of the ileocecal valve.
• 2 inches in length.
• presentation before the age of two.

3. • Wall layers of the intestine
• Natural opening of the vasa recta
• Mucosa and submucosa
• Anywhere but sigmoid most common
• Sigmoid “left” → pressure
• Right colon is common in Asian usually true and in general is rare
• The etiology of diverticulosis is inconclusive
• Diverticulitis Etiology is not clear
• Inflammation >>> bacterial growth >> distention >>> compromised blood supply >>
perforation (macro OR micro) >>> peritonitis and other complications
• Fistula formation (colovesical is common in males and colouterus in females )
• Uncommonly (in females) colocutaneous and colovaginal

4. • Less than 5% before the age of 40
• Increased incidence with the number of diverticulosis (15-20%)
• Only 20% younger than 50 years
• Industrial countries >>> lifestyle
• Asian countries adopted this lifestyle
• Coexisting conditions
• Younger patients
• Immunosuppressed
• Complication
• Abscess
• Fistula
• Intestinal rupture
• Peritonitis

5. Symptoms according to location of the affected diverticulum
• Left lower quadrant pain 70%
• Pain is crampy and associated with changed bowel habit
• Other symptoms:
• Nausea and Vomiting.
• Constipation.
• Diarrhea.
• Flatulence.
• Bloating.
• Asymptomatic
• Mimic acute appendicitis if lower right quadrant
Signs revealed on physical examination:
• Localized abdominal tenderness
• Tender palpable mass
• Abdomen may be distended
• Unremarkable signs in patient on Corticosteroids

6. • 17-40% of lower GI bleeding (most common cause)
• Most is self-limited in 80%
• Lactated Ringer
• Packed RBCs
• In severe bleeding → resuscitative measures
• Bowel preparation → Colonoscopy
• Endoscopic therapeutic measures for lesion detected by colonoscopy
• Epinephrine or electrocautery treatment
• Endoclips or band ligation
• For lesion not detected by Colonoscopy
• Radionuclide imaging
• Arteriography
• Treatment modalities
• Embolization (effectively controls hemorrhage in 76% to 100%)
• Injection vasopressin (seldom used clinically because rebleeding rate is
50%)

7. • Surgery
• Directed segmental resection
• Subtotal colectomy
• uncontrolled, massive, nonlocalized lower GI bleeding
refractory to other interventions
• In patients with 2 or more episodes of diverticular
hemorrhage, elective resection should be considered