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Diverticular disease

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Diverticular disease

  1. 1. Diverticular Disease Dr. Matt W. Johnson
  2. 2. Introduction & Overview • • • • Pathology Physiology Location Complications – – – – Bleeding Obstruction Fistula Acute Diverticulitis • Management of Acute Diverticulitis
  3. 3. Pathology • Congenital • Acquired – association with Western diets high in refined carbohydrates and low in dietary fibre1 – Deficiency of vegetable fibre in diet2 – Disordered motility – Hyperelastosis may lead to structure change – Collagen abnormalities – Age • Diverticular disease occurs in over 25% of the population, increasing with age3 1 Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005
  4. 4. Physiology • • • • • La Place effects High intra-luminal pressure Resultant characteristic protrusion mucosa Worst at terminal arterial branches Rectal sparing – ?due to complete layer of longitudinal muscle and large diameter
  5. 5. Physiology and Anatomy •Terminal arterial branches •Penetrate circular muscle •Often lie adjacent to taenia
  6. 6. Location • Classically Sigmoid • In Orient often right-sided • Rectal Sparing • Can occur anywhere (but considered separately) e.g. Small bowel –see later
  7. 7. Right vs. Left
  8. 8. Complications • Obstruction • Bleeding • Inflammation “itis” – Fistula – Sepsis – Perforation • May co-exist with IBD Specimen showing blood in diverticulae
  9. 9. Obstruction in Diverticular Disease • • • • Progressive distension Single contrast enema will delineate this Often present like cancer Diagnosis – often only at operation (opened specimen) or – on histology
  10. 10. Bleeding in Diverticular Disease • Rarely exsanguinating • Often requires repeat transfusion • Consider mesenteric angiography if available – Embolisation (risk of ischaemia and infarction) – Allows targeted resection • Operative intervention uncommon – On table colonoscopy – Exclusion
  11. 11. Re-Bleeding Rates Re-bleeding rate Year 1 2 3 4 1 Percentage 9 10 19 25 Longstreth Am J Gastro 1997
  12. 12. Other Causes Of Colonic Bleeding • Exclude – IBD – Neoplasm – Angiodysplasia – Ischaemic colitis – Radiation proctitis – Varices
  13. 13. Fistula • Abnormal connection • Commonest communications are – Colovesical – Colovaginal (esp if prev TAH) • Colovesical Symptoms – Pneumaturia – Recurrent infections – Faecalent urine or particulates • Diagnosis of site/communication vs pathology – CD/CRC/TCC
  14. 14. Acute Diverticulitis • Abscess – Peridiverticular – Mesenteric – Pericolic • Perforation – Concealed – Free • Peritonitis (gangrenous sigmoididits) – Purulent or serous or faecal – Local or generalised or pelvic 1 Killingback Surg Clin North Am 1983
  15. 15. Emergency Presentation • Symptoms – – – – – Generally unwell Pain localising to left iliac fossa* Abdominal distension Altered bowel habit e.g. diarrhoea Nausea/Fever • Signs – LIF tenderness – *Beware RIF pain-in right sided diverticulitis and where sigmoid crosses midline – Systemic signs (T/HR/BP/WCC) – May be palpable on pR at anterior rectal wall
  16. 16. Management • • • • • • • • • • Resuscitation Analgesia Bloods ECG/Catheter/Urine Rectal examination (+/-sigmoidoscopy) CXR AXR USS CT Scan Operative intervention
  17. 17. CXR
  18. 18. AXR
  19. 19. Diverticular disease
  20. 20. CT Scan Perforated diverticulitis of the sigmoid colon-CT
  21. 21. Diverticulitis with pericolic abscess
  22. 22. Operative Picture
  23. 23. Perforation
  24. 24. Operative considerations • Serial assessment and clinical judgement – (even if Radiological perforation) • Operative indications – – – – generalized peritonitis uncontrolled sepsis, visceral perforation acute clinical deterioration • At operation – Resection better than no resection1 – Hartmann’s vs anastomosis 1 Krukowski & Matheson Br J Surg 1984
  25. 25. Anastomosis • Is there any role for primary anastomosis in the inflamed bowel? • Consider if fully resuscitated and colorectal Surgeon • Retrograde gun/washout kit • Schilling et al. 2001 Diseases of the Colon and Rectum – – – – diverticulitis with peritonitis 13 patients one stage 42 Hartmann’s procedure 7% mortality in both groups • Similar complication rates – Not a study of bowel obstruction
  26. 26. Elective Presentation • Via outpatients • Often milder version of emergency presentation • Incidental radiological finding – AXR – Contrast study e.g. Barium Enema – CT scan • Rarely if insiduous, an abscess may be found on Barium Enema as an outpatient
  27. 27. Elective resection for Diverticultis • After recovering from an episode of diverticulitis the individual risk of an urgent Hartmann’s is 1 in 2000 patient-years of follow-up. • Surgery for diverticular disease has a high complication rate • 25% of patients have ongoing symptoms after bowel resection (IBS/IBD) • No evidence to support the idea that elective surgery should follow two attacks of diverticulitis. • Further prospective trials are required. 1 Janes et al BJS 2005
  28. 28. Duodenal and Jejunal Diverticulosis • Separate from colonic diverticulosis. • Most occur in the jejunum and occasionally duodenum. • Jejunal diverticula are acquired protrusions of the mucosal lining through the muscular wall of the bowel. • Encourages particular bacterial overgrowth. • A combination of alteration of the intraluminal contents by these bacteria may result in malabsorption – Calcium – Iron – Vitamins D or B12. • Patients may present with anaemia and occasionally osteomalacia.
  29. 29. Proximal Jejunal Diverticulitis
  30. 30. Incidental Jejunal Diverticular
  31. 31. Proximal Jejunal diverticulitis with perforation
  32. 32. Questions ??

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