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Diverticulitis and Management
issues
Prakash K
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
299 pts out of 3022 colonoscopies
258 (85%) were incidental

40% right sided
46% Left colonic
13% pan colonic
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
Effect of the Industrial Revolution



No pathologic
specimens in European
museums or case

reports of diverticulitis
or diverticulosis prior to
Industrial Revolution

(~1750-1850)
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
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)
Etiology of Diverticulosis
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
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
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
Incidence
Rare under 30

40% @ 60, 60% > 80
95% sigmoid and left colon

Progressively more proximally
in Asian countries

10-25% develop diverticulitis
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
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
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.
Classification systems
• • Ambrosetti

• • Modified Hinchey
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
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
Controversies
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
Practice Parameters
• Elective resection after two documented attacks
of diverticulitis

• Complicated diverticulitis: resection after the
first attack
• Patients below 40, after first attack
Stage 0
 Generally treated with

Oral antibiotics
 Ciprofloxacin+metronid
azole
 Cephalosporins+metro

 Low residue diet initially
 High fiber diet once
symptoms resolve

 Interval colonoscopy
Stage Ia
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
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)
Stage III and IV
Complicated Diverticulitis
• Can be difficult to
distinguish on CT Scan
or clinically

• Generalized or
Localized Peritonitis
• Sepsis
• Fever
• Elevated WBC
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
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?
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
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
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
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
Can we eat Seeds, Nuts and Popcorn?

Yes!
Do all young patients (age < 50)
require sigmoid colon resection?
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
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
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
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
Surgical treatment in summary

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Surgical Management of Colonic Diverticulitis

  • 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)
  • 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
  • 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
  • 24.
  • 25. 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
  • 26. 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)
  • 27. Stage III and IV Complicated Diverticulitis • Can be difficult to distinguish on CT Scan or clinically • Generalized or Localized Peritonitis • Sepsis • Fever • Elevated WBC
  • 28. 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
  • 29. 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?
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. Can we eat Seeds, Nuts and Popcorn? Yes!
  • 35. Do all young patients (age < 50) require sigmoid colon resection?
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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