Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Divertieular disease of the colon

By
Mehameel Meurad Alv
Assistant lecturer ef general surgerv
Nomenclature

 

° Diverticulum =  A sac-like protrusion of mucosa
through the muscular colonic wall. 

° Diverticulosis =...
Epidemiology

 

° Before the 20”‘ century,  diverticular disease was
rare

° Prevalence has increased over time

- 1907 F...
Epidemiology

 .  7 7-1-' __  ' ,  '*  ' ’ " j:  T” ; ,in'-: ,' ,   ‘J---. "=-'—: _’*" ‘ -7’
l Percentage

70
60
SO
40
30
...
Epidemiology

 

° Gender prevalence depends on age

— M>>F Age less than 40
— M > F Age 40-50
— F > M Ages 50-70

— F>>M ...
Anatomic location of diverticuli varies with the

geographic location

 

° ”Westernized” nations (North America,  Europe,...
Anatomic location of diverticuli varies with the

 

geographic location

° Asia and Africa diverticulosis in general is r...
M .  _ .  . _ M . - i , 
7“l 1. '. ,r. ‘ , -V‘ u‘', «. I‘,  L I} t,  (3 ",  r ’I’_ .  ‘l_ I‘ ‘‘, I‘ ‘  I, 
M l la‘ ~. .,~....
What exactly is a diverticulum? 

 

— True diverticulum contains all layers of the GI wall
(mucosa to serosa)

- Colonic ...
T l
_ l l-
Mucosa ‘ . ,., ,,_, ._J; .- (= l,'—ll', l.| ¥' " "
H a.  ' I” V '
(ollolll '1"JU”n‘r'“’ I la‘.  ,‘
,  . ravxaie...
:‘ __ 3 2 7 V,  l.  ,' ,  
r"'7‘. l  Pf" . .' il l l', ~'  l‘ . ‘ ti» -"‘—" ‘i

4 . .

* Law of Laplace:  P =  kT/  R
* Pr...
~ Segmentation =  motility process in which the segmental
muscular contractions separate the lumen into chambers

- Segmen...
Lifestyle factors associated with

diverticular disease

° Low fiber 9 diverticular disease

 

— Not absolutely proven in...
Lifestyle factors associated with

diverticular disease

 

° Obesity associated with diverticulosis —
particularly in men...
Asymptomatic

    
   
   
  

DIVERTICULOSIS

Diverticular
bleeding

(5-15%)

Diverticulitis
(15-25%)

Complicated

25%

...
° Usually an incidental finding at time of
colonoscopy

‘ ‘_p, “ .  V‘ " E, C
c v 5’.  _ _ :3 .  1}‘? -
. . -o , A car 3.:...
Dx
Uncomplicated diverticulosis

 

° Considered ‘asymptomatic’

° However,  a significant minority of patients will
complain...
Uncomplicated diverticulosis

 

° Treatment:  Fiber

— Bulk content reduces colonic pressure preventing
underlying pathop...
Diverticulitis

 

° Diverticulitis =  inflammation of diverticuli

0 Most common complication of diverticulosis

° Occurs...
Pathophysiology of Diverticulitis

 

° Micro or macroscopic perforation of the
diverticulum 9 subclinical inflammation to...
l  '.   -" .  _ of  m‘~"‘. ‘
 l'; " ‘Pi Jar ‘I if 7" / ii  )1,‘ V3 V1’,  ‘ 1'  l)_. lr. :‘, :'l‘ {fl  ‘

* Increased intra...
i*: =i‘i: *i J-~  ' -. ‘Jl'*': ‘l’Ll; -l *~ “cl: 
7
Diverticulitis
I
Simple Complicated
75% l I 25%
Free l Intestinal
Absc...
Diagnosis of Diverticulitis

 

° Classic history:  increasing,  constant,  LLQ
abdominal pain over several days prior to
...
Diagnosis of Diverticulitis

 

° Previous of episodes of similar pain

° Associated symptoms
— Nausea/ vomiting 20-62%
— ...
Diagnosis of Diverticulitis

 

Right sided diverticulitis tends to cause RLQ
abdominal pain;  can be difficult to disting...
Diagnosis of Diverticulitis

 

° Physical examination

— Low grade fever

— LLQ abdominal tenderness
° Usually moderate w...
Diagnosis of Diverticulitis

 

° Clinically,  diagnosis can be made with typical
history and examination

° Radiographic ...
Treatment of Diverticulitis

 

° Complicated diverticulitis =  Presence of
macroperforation,  obstruction,  abscess,  or ...
Uncomplicated diverticulitis

 

- Bowel rest or restriction

- Clear liquids or NPO for 2-3 days
— Then advance diet

° A...
Uncomplicated diverticulitis

 

- Monitoring clinical course
— Pain should gradually improve several days (decrescendo)
—...
Uncomplicated diverticulitis

 

° Follow-up:  Colonoscopy in 4-6 weeks

° Purpose

 

— Exclude neoplasm

A

— Evaluate e...
Prognosis after resolution

Prognosis after 1st attack

4?‘. 
(‘X

Asym ptomaic 30-
40%

“ abdominal cramps
30-40%

' seco...
* Second attack
— Risk of recurrent attacks is high (>50%)

— Some studies suggest a higher rate (60%) of
complications (a...
Prognosis after resolution

 

- Some argue in the elderly recurrent attacks can
be managed with medications

elective sur...
Complicated diverticulitis

Complicated
diverticulitis

Free
perforation &
peritonitis

Intestinal
obstruction
Complicated Diverticulitis:  Abscess

 

° Abscess
— Occurs in 16% of patients with acute diverticulitis

- Percutaneous d...
Complicated Diverticulitis:  Abscess

 

° Small abscesses too small to drain
percutaneously (< 1cm) can be treated with
a...
Complicated Diverticulitis:  Abscess

 

° CT guided drain

— Leave in until drain output less than 10 mL in 24
hours

— M...
Complicated Diverticulitis:  Peritonitis

 

- Peritonitis
— Resuscitation
— Antibiotics
° Ampicillin + Gentamycin + Metro...
Hinchey classification 1978

 

Stage Characteristics

I Localized pericolic or mesenteric abscess
ll Confined pelvic absc...
Ila

llb

llc

Hansen Stock staging 1999

Diverticulosis

Acute unconiplicaied
diverticulitis

Acute complicated
diverticu...
My l H,    _ir"’»I: _-N*"r; '*' L W”? !  ‘ L': "_5
° Fistula , 
‘A
 ‘ ‘
Complicated Diverticulitis:  Fistulas

l

° Occurs in up to 80% of cases requiring surgery

Percentage
70

60
50
40
30
20
...
Complicated Diverticulitis:  Fistulas -

Svmptoms

 

° Passage of gas and stool from the affected organ

° Colovesical fi...
Complicated Diverticulitis:  Fistulas

 

° Diagnosis
— CT scan:  thickened bladder with associated colonic
diverticuli ad...
Complicated Diverticulitis:  Treatment of

Fistulas

 

° Surgery
- Resection of affected colon (origin of the fistula)
— ...
Algorithm for treatment

  

Mulru-mu‘

Diverticulosis

     

_

Symproman uncom Ircaled disease
(no nllam ation)

Divert...
Algorithm of acute diverticulitis

 

 

   
     
   

F Acute divezrticulitis 
r ~ ‘E r _ / . r ‘fl    r

 
  
  
 
  
 ...
‘,  ‘.4 7 J g

 ll»'; li: ;”il: ;t-all r‘r: ~’~. :*l3  F‘  vi ‘tr’: 

° Elective single stage resection is ideal,  "6 week...
Diverticular bleeding

 

° Most common cause of massive hematochezia
(30-50% of cases)

° 15% of patients with diverticul...
Diverticular bleeding

 

Patients requiring less than 4 units of PRBC/  day 9
99% will stop bleeding

Risk of rebleeding ...
Diverticular bleeding:  Pathophysiology

 

° Diverticulum herniates at site of vasa recta

° Over time,  the vessel becom...
Diverticular bleeding;  symptoms

ll ‘K P‘: 

 

° Most only have symptoms of bloating and
diarrhea but no significant abd...
Diverticular bleeding: 

 

Management

° Resuscitation
- Localization

° Supportive care with blood products
Diverticular bleeding:  Localization

 

° Right colon is the source of diverticular bleeding
in 50-90% of patients

° Pos...
Diverticular bleeding: 

 

 
 
 
  
      

localization , 

     
   

    
  

_ if 

lCo| onoscopyl» ‘Tagged RBCS l
 (...
Diverticular bleeding: 

 

Localization

Colonoscopy after rapid preparation
— Can localize site of bleeding

 

— Offers...
Diverticular bleeding: 
Management
Diverticular bleeding:  Localization

 

° Tagged red blood cell scan

- Can localize bleeding source
° 97% sensitivity
° ...
Diverticular bleeding:  Localization

 

° Angiography
- Accurate localization

° 30-47% sensitive
- 100% specific

— Need...
Diverticular bleeding:  Surgery

 

° Surgery
— Segmental resection

° If site can be localized
' Rebleeding rate of 0-14%...
Lapargscopic scgmeisiectemv
for diver colitis
Diverticular disease of the colon
Diverticular disease of the colon
Diverticular disease of the colon
Diverticular disease of the colon
Upcoming SlideShare
Loading in …5
×

Diverticular disease of the colon

3,775 views

Published on

Colonic diverticulosis diagnosis and treatment

Published in: Health & Medicine

Diverticular disease of the colon

  1. 1. Divertieular disease of the colon By Mehameel Meurad Alv Assistant lecturer ef general surgerv
  2. 2. Nomenclature ° Diverticulum = A sac-like protrusion of mucosa through the muscular colonic wall. ° Diverticulosis = describes the presence of diverticuli ° Diverticulitis = inflammation of diverticuli
  3. 3. Epidemiology ° Before the 20”‘ century, diverticular disease was rare ° Prevalence has increased over time - 1907 First reported resection of complicated diverticulitis by Mayo -1925 5-10% -1969 35-50%
  4. 4. Epidemiology . 7 7-1-' __ ' , '* ' ’ " j: T” ; ,in'-: ,' , ‘J---. "=-'—: _’*" ‘ -7’ l Percentage 70 60 SO 40 30 20 10 Age 40 Age 60 Age 85 ' Percentage
  5. 5. Epidemiology ° Gender prevalence depends on age — M>>F Age less than 40 — M > F Age 40-50 — F > M Ages 50-70 — F>>M Ages > 70
  6. 6. Anatomic location of diverticuli varies with the geographic location ° ”Westernized” nations (North America, Europe, Australia) have predominantly left sided diverticulosis — 95% diverticuli are in sigmoid colon — 35% can also have proximal diverticuli — 4% have only right sided diverticuli
  7. 7. Anatomic location of diverticuli varies with the geographic location ° Asia and Africa diverticulosis in general is rare and usually right sided — Prevalence < 0.2% — 70% diverticuli in right colon in Japan
  8. 8. M . _ . . _ M . - i , 7“l 1. '. ,r. ‘ , -V‘ u‘', «. I‘, L I} t, (3 ", r ’I’_ . ‘l_ I‘ ‘‘, I‘ ‘ I, M l la‘ ~. .,~. i i. ~ ~. «i. i- . « * Colonic diverticulosis is actually not a true diverticulum but rather a pseudo—diverticulum True Diverticulum Pseudodiverticulum Includes the muscle Thr°"'9h the muscle Examples: Examples: Mecl<eI's Zenl<er's esophageal Normal appendix Common colon "ticks"
  9. 9. What exactly is a diverticulum? — True diverticulum contains all layers of the GI wall (mucosa to serosa) - Colonic pseudo—diverticulum more like a local hernia ° Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa
  10. 10. T l _ l l- Mucosa ‘ . ,., ,,_, ._J; .- (= l,'—ll', l.| ¥' " " H a. ' I” V ' (ollolll '1"JU”n‘r'“’ I la‘. ,‘ , . ravxaieiiei W ' n: l»IlT‘-. l~ ' ~ 4 l ‘ » 4 - ainltz , _. ‘hpw (uiggi gl—lll : Submucosa '7" ' ‘ I j J in-. _‘~m'-'I= ' W? " : Muscularis Vasa recta / Serosa
  11. 11. :‘ __ 3 2 7 V, l. ,' , r"'7‘. l Pf" . .' il l l', ~' l‘ . ‘ ti» -"‘—" ‘i 4 . . * Law of Laplace: P = kT/ R * Pressure = K x Tension / Radius it Sigmoid colon has small diameter resulting in highest pressure zone
  12. 12. ~ Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers - Segmentation 9 increased intraluminal pressure 9 mucosal herniation 9 Diverticulosis ? §E$$| .J9E TRACE LEAD 2- ‘I Scot-Users! contraclirsg l; rv-tr! opera Scgrv-u¢r1l contracting lurvaclfi o<: c|. nd¢d.
  13. 13. Lifestyle factors associated with diverticular disease ° Low fiber 9 diverticular disease — Not absolutely proven in all studies but strongly suggested — Western diet is low in fiber with high prevalence of diverticulosis — In contrast, African diet is high in fiber with a low prevalence of diverticulosis
  14. 14. Lifestyle factors associated with diverticular disease ° Obesity associated with diverticulosis — particularly in men under the age of 40 ° Lack of physical activity
  15. 15. Asymptomatic DIVERTICULOSIS Diverticular bleeding (5-15%) Diverticulitis (15-25%) Complicated 25% Abscess Obstruction Perforation Fistula
  16. 16. ° Usually an incidental finding at time of colonoscopy ‘ ‘_p, “ . V‘ " E, C c v 5’. _ _ :3 . 1}‘? - . . -o , A car 3.: . . ~._ - £4 ‘ . ~. __ ‘ x_, _ __ - : .- '4 9" 3'. '. _
  17. 17. Dx
  18. 18. Uncomplicated diverticulosis ° Considered ‘asymptomatic’ ° However, a significant minority of patients will complain of cramping, bloating, irregular BlVlS, narrow caliber stools — IBS? — Recent studies demonstrate motility abnormalities in patients with ‘symptomatic’ uncomplicated diverticulosis Bloating
  19. 19. Uncomplicated diverticulosis ° Treatment: Fiber — Bulk content reduces colonic pressure preventing underlying pathophysiology that lead to diverticulosis — 20 to 30 g fiber per day is needed; difficult to get with diet alone
  20. 20. Diverticulitis ° Diverticulitis = inflammation of diverticuli 0 Most common complication of diverticulosis ° Occurs in 15-25% of patients with diverticulosis
  21. 21. Pathophysiology of Diverticulitis ° Micro or macroscopic perforation of the diverticulum 9 subclinical inflammation to generalized peritonitis
  22. 22. l '. -" . _ of m‘~"‘. ‘ l'; " ‘Pi Jar ‘I if 7" / ii )1,‘ V3 V1’, ‘ 1' l)_. lr. :‘, :'l‘ {fl ‘ * Increased intraluminal pressure 9 Erosion of diverticular wall 9 inflammation 9 focal necrosis 9 perforation * Usually inflammation is mild and microperforation is walled off by pericolonic fat and mesentery , L , ,,W, ,_, , l diverticuia opening adam. com
  23. 23. i*: =i‘i: *i J-~ ' -. ‘Jl'*': ‘l’Ll; -l *~ “cl: 7 Diverticulitis I Simple Complicated 75% l I 25% Free l Intestinal Abscess Fistula perforation& , obstruction I peritonitis - I K / ' K / ‘ K / k /
  24. 24. Diagnosis of Diverticulitis ° Classic history: increasing, constant, LLQ abdominal pain over several days prior to presentation with fever — Crescendo quality — each day is worse — Constant — not colicky — Fever occurs in 57-100% of cases
  25. 25. Diagnosis of Diverticulitis ° Previous of episodes of similar pain ° Associated symptoms — Nausea/ vomiting 20-62% — Constipation 50% - Diarrhea 25-35% — Urinary symptoms (dysuria, urgency, frequency) 10-15%
  26. 26. Diagnosis of Diverticulitis Right sided diverticulitis tends to cause RLQ abdominal pain; can be difficult to distinguish from appendicitis
  27. 27. Diagnosis of Diverticulitis ° Physical examination — Low grade fever — LLQ abdominal tenderness ° Usually moderate with no peritoneal signs - Painful mass in 20% of cases ° Rebound tenderness suggests free perforation and peritonitis ° Labs : Mild leukocytosis — 45% of patients will have a normal WBC
  28. 28. Diagnosis of Diverticulitis ° Clinically, diagnosis can be made with typical history and examination ° Radiographic confirmation is often performed — Rules out other causes of an acute abdomen — Determines severity of the diverticulitis (complications)
  29. 29. Treatment of Diverticulitis ° Complicated diverticulitis = Presence of macroperforation, obstruction, abscess, or fistula ° Uncomplicated diverticulitis = Absence of the above complications
  30. 30. Uncomplicated diverticulitis - Bowel rest or restriction - Clear liquids or NPO for 2-3 days — Then advance diet ° Antibiotics — Coverage of fecal flora ° Gram negative rods, anaerobes — Common regimens ° Cipro + Flagyl x 10 days - Augmentin or Unsayn x 10 days
  31. 31. Uncomplicated diverticulitis - Monitoring clinical course — Pain should gradually improve several days (decrescendo) — Normalization of temperature - Tolerance of PO intake - If symptoms deteriorate or fail to improve with 3 days, then Surgery consult ° Early elective surgery 7-10 days after the acute attack
  32. 32. Uncomplicated diverticulitis ° Follow-up: Colonoscopy in 4-6 weeks ° Purpose — Exclude neoplasm A — Evaluate extent of the diverticulosis
  33. 33. Prognosis after resolution Prognosis after 1st attack 4?‘. (‘X Asym ptomaic 30- 40% “ abdominal cramps 30-40% ' second attack 20- 30%
  34. 34. * Second attack — Risk of recurrent attacks is high (>50%) — Some studies suggest a higher rate (60%) of complications (abscess, fistulas, etc) in a second attack and a higher mortality rate (2x compared to initial attack) After a second attack 9 elective surgery l
  35. 35. Prognosis after resolution - Some argue in the elderly recurrent attacks can be managed with medications elective surgery should be considered after a first attack in ° Young patients under 40-50 years of age ° lmmunosuppressed
  36. 36. Complicated diverticulitis Complicated diverticulitis Free perforation & peritonitis Intestinal obstruction
  37. 37. Complicated Diverticulitis: Abscess ° Abscess — Occurs in 16% of patients with acute diverticulitis - Percutaneous drainage followed by single stage surgery in 60-80% of patients Enl argei Image for Dl'F*3I’llCl. llll'iS Diverticula Diverticulitis with rupture
  38. 38. Complicated Diverticulitis: Abscess ° Small abscesses too small to drain percutaneously (< 1cm) can be treated with antibiotics alone ° These patients behave like uncomplicated diverticulitis and may not require surgery
  39. 39. Complicated Diverticulitis: Abscess ° CT guided drain — Leave in until drain output less than 10 mL in 24 hours — May take up to 30 days
  40. 40. Complicated Diverticulitis: Peritonitis - Peritonitis — Resuscitation — Antibiotics ° Ampicillin + Gentamycin + Metronidazole ° Imipenem/ cilastin ° Zosyn — Emergency exploration — Mortality 6% purulent peritonitis and 35% fecal peritonitis
  41. 41. Hinchey classification 1978 Stage Characteristics I Localized pericolic or mesenteric abscess ll Confined pelvic abscess Ill Generalized purulent peritonitis resulting from perforation of an abscess IV Generalized fecal peritonitis secondary to free colonic perforation
  42. 42. Ila llb llc Hansen Stock staging 1999 Diverticulosis Acute unconiplicaied diverticulitis Acute complicated diverticulitis Peridiverticulitis. phlegmonous diverticulitis Abscess forming diverticulitis. covered perforation. fistula Free perforation Chronic recurrent diverticulitis Clinical signs None Lower abdominal pain, lever in some cases Tenderness or localized guarding. palpable lower abdominal mass, fever Local peritonism. fever. ileus Acute abdomen Anamnesiically recurrent lower abdominal pain. in some cases lever. in some cases constipation or subileus. in some cases pneumaturia Colonoscopy/ CE Inflammation-free diverticulum Endoscopy: reddened mucosa around the neck of the diverticulum. CE: spicules. intestinal wall thickening Endoscopyzreddened mucosa around the neck of the diverticulum. CE: spicules. intestinal wall thickening Endoscopy: reddened mucosa around the neck of the diverticulum. CE: spicules, intestinal wall ttiickening. in some cases extra luminal CM Not indicated Endoscopy or CE: stenosis. fistula Abdominal CT Diverticulum filled with gas or contrast medium and in some cases intestinal wall thickening and density increase in pericolic fatty tissue and mesocolic or retroperitoneal abscess Free air. free liquid. in some cases abscesses Intestinal wall thickening, in some cases stenosis or fistula
  43. 43. My l H, _ir"’»I: _-N*"r; '*' L W”? ! ‘ L': "_5 ° Fistula , ‘A ‘ ‘
  44. 44. Complicated Diverticulitis: Fistulas l ° Occurs in up to 80% of cases requiring surgery Percentage 70 60 50 40 30 20 10 0 Colovesical colovaginal coloenteric, colouterine Percentage
  45. 45. Complicated Diverticulitis: Fistulas - Svmptoms ° Passage of gas and stool from the affected organ ° Colovesical fistula: — pneumaturia, dysuria, fecaluria — 50% of patients can have diarrhea and passage of urine per rectum
  46. 46. Complicated Diverticulitis: Fistulas ° Diagnosis — CT scan: thickened bladder with associated colonic diverticuli adjacent and air in the bladder — Barium Enema: direct visualization of fistula track only occurs in 20-26% of cases — Cystogram may be helpful — Flexible sigmoidoscopy is low yield (0-3%) — Some argue cystoscopy helpful
  47. 47. Complicated Diverticulitis: Treatment of Fistulas ° Surgery - Resection of affected colon (origin of the fistula) — Fistula tract can be ”pinched off” most of the time — Suture closure for larger defects - Foley left in 7-10 days
  48. 48. Algorithm for treatment Mulru-mu‘ Diverticulosis _ Symproman uncom Ircaled disease (no nllam ation) Diverticular disease :9 Fiber supleme alion Broad s - rum a tibiotics fiw "‘1M| "i'. I~ll I‘ ':1‘lIl“, J
  49. 49. Algorithm of acute diverticulitis F Acute divezrticulitis r ~ ‘E r _ / . r ‘fl r -5 F 1 , .. : stage I Stage II a Stage II b if Stage II c I Uncomplicated Phlegmons Abscess I , 7.: Conservative! if necessary Emergency I drainage ‘H surgery .9. , V ,2-———: . ‘l: .,~T_: _:. ._ ] Substantial improvement after approx. 48 h ' , "ve"s. ' ‘ E u}g, ¢n. ;;. };; ;§ »— ‘ ' (Early) Elective l‘ surgery I, _ ’m, -_. _.. __: __a. l -' 1 - — ~ -— »——: -V ~- + l A Continued Complaintslafter approx. 1 week i conservative l.
  50. 50. ‘, ‘.4 7 J g ll»'; li: ;”il: ;t-all r‘r: ~’~. :*l3 F‘ vi ‘tr’: ° Elective single stage resection is ideal, "6 weeks after episode - Two stage procedure (Hartmann procedure) — Sigmoid resection n kl — Colostomy . , - Rectal stump - 3 months later 9 colostomy takedown and colorectal anastomosis
  51. 51. Diverticular bleeding ° Most common cause of massive hematochezia (30-50% of cases) ° 15% of patients with diverticulosis will bleed ° 75% of diverticular bleeding stops without need for intervention Bleedingdlvertlcula adam. com
  52. 52. Diverticular bleeding Patients requiring less than 4 units of PRBC/ day 9 99% will stop bleeding Risk of rebleeding 9 14-38% After second episode of bleeding, risk of rebleeding 9 21-50%
  53. 53. Diverticular bleeding: Pathophysiology ° Diverticulum herniates at site of vasa recta ° Over time, the vessel becomes draped over the dome of the diverticulum separated only by mucosa ° Over time, there is segmental weakening ofthe artery 9 ruptures and bleeds 3. ! ‘if W‘ , 5" ’. V’ r
  54. 54. Diverticular bleeding; symptoms ll ‘K P‘: ° Most only have symptoms of bloating and diarrhea but no significant abdominal pain — Painless hematochezia — Sta rt — stop pattern; ”water faucet” ° Diverticulitis rarely causes bleeding
  55. 55. Diverticular bleeding: Management ° Resuscitation - Localization ° Supportive care with blood products
  56. 56. Diverticular bleeding: Localization ° Right colon is the source of diverticular bleeding in 50-90% of patients ° Possible reasons — Right colon diverticuli have wider necks and domes exposing vasa recta over a great length of injury — Thinner wall of the right colon
  57. 57. Diverticular bleeding: localization , _ if lCo| onoscopyl» ‘Tagged RBCS l ( scan L. 1. l ‘r
  58. 58. Diverticular bleeding: Localization Colonoscopy after rapid preparation — Can localize site of bleeding — Offers possible therapeutic intervention (cautery, clip, etc. ) — Often limited by either brisk bleeding obscuring lumen OR no active bleeding with clots in every diverticuli
  59. 59. Diverticular bleeding: Management
  60. 60. Diverticular bleeding: Localization ° Tagged red blood cell scan - Can localize bleeding source ° 97% sensitivity ° 83% specificity ° 94% PPV — Can detect bleeding as slow as 0.1 mL/ min — Often not particularly helpful
  61. 61. Diverticular bleeding: Localization ° Angiography - Accurate localization ° 30-47% sensitive - 100% specific — Need brisk active bleeding: 0.5-1 mL/ min — Offers therapy: embolization, vasopressin - 20% risk of intestinal infarction
  62. 62. Diverticular bleeding: Surgery ° Surgery — Segmental resection ° If site can be localized ' Rebleeding rate of 0-14% — Subtotal colectomy ° Rebleeding rate is 0% ° High morbidity (37%) - High mortality (11—33%)
  63. 63. Lapargscopic scgmeisiectemv for diver colitis

×