Diverticular disease of colon


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Diverticular disease of colon

  1. 1. Diverticular DiseaseDR. RAJNISHDR. ALTAMASH
  2. 2. Nomenclature Diverticulum = sac-like protrusion of the gut wall Diverticulosis = describes the presence of diverticuli Diverticulitis = inflammation of diverticuli
  3. 3. Epidemiology Before the 20th 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 Increases with age  Age 40 <5%  Age 60 30%  Age 85 65%
  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. What exactly is a diverticulum?Mostly Diverticulosis is actually not a true diverticulum but rather a pseudo-diverticulum  True diverticulum contains all layers of the GI wall (mucosa to serosa), eg congenital diverticula, traction diverticula. Pseudo-diverticulum more like a local hernia Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa
  7. 7. TYPES OF DIVERTICULA1 Congenital. All three coats of the bowel are present in thewall of the diverticulum, e.g. Meckel’s diverticulum.2 Acquired. The wall of the diverticulum lacks a propermuscular coat in most cases. Most alimentary diverticula arethought to be acquired. PULSION DIVERTICULA: develop at a site of weakness as a result of chronic pressure against an obstruction.eg, Epiphrenic diverticula, Zenker,s diverticula, most colonic diverticula TRACTION DIVERTICULA:Fibrotic healing of the lymph nodes exerts traction on the oesophageal wall and produces a focal outpouching,eg Mid-oesophageal diverticula. It is a true diverticula
  8. 8. 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 5% diverticuli are from pharynx to descending colon Asia and Africa diverticulosis in general is rare and usually right sided  Prevalence < 0.2%
  9. 9. OESOPHAGEAL DIVERTICULA1.Pharyngoesophageal2.Midesophageal3.epiphrenic
  10. 10. Small Intestine diverticula Most of these diverticula arise from the mesenteric side of the Bowel.Duodenal diverticula1 Primary. Mostly occurringin older patients on the innerwallof the second and thirdparts2 Secondary. Diverticula ofthe duodenal cap result fromlongstandingduodenal ulceration
  11. 11. Jejunal And Meckel’sDiverticulum
  12. 12. Meckel’s Diverticulum It is a true diverticulaOccurs in 2% of patients, are usually 2 inches (5 cm) inlength and are situated 2 feet (60 cm) from the ileocaecalValve It should be sought when a normal appendix is found atsurgery for suspected appendicitisIt represents the patent intestinal end of the vitellointestinal duct
  13. 13. Colonic DiverticulaClassically Sigmoid 95% of all diverticuliRectal Sparing The taeniae coalesce to form an enveloping muscular layer in the rectum. Much of the colonic wall is therefore devoid of longitudinal muscle and it is in these areas that diverticula form.
  14. 14. Diverticular Disease
  15. 15. Pathophysiology Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall
  16. 16. MucosaSubmucosaMuscularis Vasa recta Serosa
  17. 17. Diverticula do not arise randomly around thecircumferenceof the colon T h e y o r i g i n a t e i n f o u r d i s t i n c t r o w s t h a t c o r r e s p o n d t o t h e f o u r s i t e s o f p e n e t r a
  18. 18. Diverticular Disease-macroscopic
  20. 20. Pathophysiology Law of Laplace: P = kT / R Pressure = K x Tension / Radius Sigmoid colon has small diameter resulting in highest pressure zone
  21. 21. Pathophysiology Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers Segmentation  increased intraluminal pressure  mucosal herniation  Diverticulosis May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation Compounded by the hyperelastosis, increase in elastin deposition between the muscle cells in the taenia and altered collagen structure seen in the colon due to aging
  22. 22. Painter proposed a theoryof segmentation,postulatingthat contraction of the colonat haustral folds caused thecolon to act not as acontinuous tube butas a series of discrete “littlebladders,” which led toexcessively high pressureswithin each segment
  23. 23. Lifestyle factors associatedwith diverticular disease Low fiber  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
  24. 24. Lifestyle factors associatedwith diverticular disease Obesity associated with diverticulosis – particularly in men under the age of 40 Lack of physical activity
  25. 25. Uncomplicated diverticulosis Considered ‘asymptomatic’ However, a significant minority of patients will complain of cramping, bloating, irregular BMs, narrow caliber stools  IBS?  Recent studies demonstrate motility abnormalities in pts with ‘symptomatic’ uncomplicated diverticulosis
  26. 26. 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 of the artery  ruptures and bleeds
  27. 27. Diverticular bleeding: Pathophysiology
  28. 28. Diverticulitis Diverticulitis = inflammation of diverticuli Most common complication of diverticulosis Occurs in 10-25% of patients with diverticulosis
  29. 29. Pathophysiology ofDiverticulitis Micro or macroscopic perforation of the diverticulum  subclinical inflammation to generalized peritonitis Previously thought to be due to fecaliths causing increased diverticular pressure; this is really rare
  30. 30. Pathophysiology ofDiverticulitis Erosion of diverticular wall from increased intraluminal pressure  inflammation  focal necrosis  perforation Usually inflammation is mild and microperforation is walled off by pericolonic fat and mesentery
  32. 32. MANAGEMENT OF PHARYNGOESOPHAGEALDIVERTICULA DIAGNOSIS is confirmed by typical clinical presentations like:  Dysphagia , Regurgitation ,  Aspiration,  Halitosis, excessive salivation, and a "lump in the throat" ,INVESTIGATION: Barium swallow and endoscopy TREATMENT: Endoscopically Pouch excision Diverticulopexy(pouch suspension) Myotomy of cricopharyngeous
  33. 33. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA ENDOSCOPIC PROCEDURE A. Exposure of the esophagus and diverticulum is gained with a diverticuloscope placed perorally. B. The linear stapler is placed across the cricopharyngeus muscle by placing a blade in the esophagus and the diverticulum.
  34. 34. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA OPEN PROCEDURE The linear stapler is placed across the neck of the diverticulum. Note that the bougie is in place before transecting the diverticulum
  35. 35. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULAMid-oesophageal diverticula: Are usually traction diverticula of no particularconsequence. The underlying motility disorder doesnot usually require treatment.Epiphrenic diverticula:Large diverticula may be excised, and this shouldbe combined with a myotomy from the site of thediverticulum down to the cardia to relievefunctional obstruction
  36. 36. Management 0f Duodenal diverticulaMostly occurring in older patients Usually asymptomatic. Can cause problems locating the ampulla during endoscopicretrograde cholangiopancreatography (ERCP).If symptomatic resection and anastomosis can be done
  37. 37. Management 0f Jejunal diverticulaClinically, they may be symptomless give rise to abdominal Pain produce a malabsorption syndrome present as an acute abdomen with acuteinflammation and occasionally perforationTREATMENT:Resection of the affected segment with end-to-endanastomosis can be effective
  38. 38. Management of Meckel’s diverticulum■ If a silent Meckel’s is found incidentally during the courseof an operation, it can be left alone provided it is widemouthed and not thickened■ If ectopic gastric epithelium is present within thediverticulum, it may be the source of gastrointestinalbleeding, should be removed surgically
  39. 39. Management of Meckel’s diverticulumMeckel’s diverticulectomySteps in the performance of Meckelian diverticulectomy
  40. 40. MANAGEMENT OF COLONIC DIVERTICULUM Diagnosis is established by clasical history, physical examination and investigation  Classic history: increasing OR constant, LLQ abdominal pain over several days prior to presentation with fever, NATURE OF PAIN  Crescendo quality – each day is worse  Constant – not colicky  Fever occurs in 57-100% of cases
  41. 41. MANAGEMENT OF COLONIC DIVERTICULUM  Previous of episodes of similar pain  Associated symptoms  Nausea/vomiting 20-62%  Constipation 50%  Diarrhea 25-35%  Urinary symptoms (dysuria, urgency, frequency) 10-15%
  42. 42. Contd. Physical examination  Low grade fever  LLQ abdominal tenderness  Usually moderate with no peritoneal signs  Painful pseudo-mass in 20% of cases  Rebound tenderness suggests free perforation and peritonitis Labs : Mild leukocytosis  45% of patients will have a normal WBC
  43. 43. Contd. Right sided diverticulitis tends to cause RLQ abdominal pain; can be difficult to distinguish from appendicitis
  44. 44. Contd. 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
  45. 45. Investigations   [Abdominal X-ray, barium study]  Barium enemas show diverticula as globular outpouchings on X-ray film. They typically have a signet- ring appearance due to the filling defect produced by contained faecoliths.www.mediscan.co.uk/cfm/resultssearch.cfm?box=...
  47. 47. InvestigationsDiverticular strictures can simulate annularcarcinomas on barium X-ray as both have an ‘apple-core’ appearance. Therefore an endoscope is alsoneeded for confirmation.Diverticulosis- barium enema (colonoscopy)Diverticulitis- CBC, CT scanDiverticular mass/paracolic abscess- CT scan
  48. 48. Flexible sigmoidoscopy can visualise colonicdiverticula. ( Colonoscopy may also be able to visualiseaffected segments)
  50. 50. Treatment of Diverticulitis Complicated diverticulitis = Presence perforation, obstruction, abscess, or fistula formation. Uncomplicated diverticulitis = Absence of the above complications
  51. 51. Treatment of Uncomplicated diverticulitis Bowel rest or restriction  Clear liquids or NPO for 2-3 days  Then advance diet  Bulk purgatives Antibiotics Lifestyle modification : weight control
  52. 52. Treatment Uncomplicated diverticulitiscontd.. 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. After resolution of attack  high fiber diet with supplemental fiber is advised
  53. 53. Treatment Uncomplicated diverticulitiscontd.. Follow-up: Colonoscopy in 4-6 weeks Flexible sigmoidoscopy and BE reasonable alternative Purpose  Exclude neoplasm  Evaluate extent of the diverticulosis
  54. 54. Prognosis after resolution ofuncomplicated diverticulitis 30-40% of patients will remain asymptomatic 30-40% of pts will have episodic abdominal cramps without frank diverticulitis 20-30% of pts will have a second attack After a second attack  elective surgery
  55. 55. Prognosis after second attack 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)Some argue elective surgery should be considered after a firstattack in  Young patients under 40-50 years of age  Immunosuppresed
  56. 56. Treatment of complicated diverticulitis
  57. 57. Treatment ComplicatedDiverticulitis: AbscessHINCHEY CLASSIFICATIONStage I Diverticulitis with associated pericolic abscessStage II Diverticulitis associated with distant abscess (retroperitoneal or pelvic)Stage III Diverticulitis associated with purulent peritonitisStage IV Diverticulitis associated with fecal peritonitis
  58. 58. STAGE i and STAGE ii is suitablymanaged with drainage andantibioticsSTAGE iii and STAGE iv usuallyrequiring surgery
  59. 59. Treatment Complicated Diverticulitis: AbscessSmall <5 cm abscesses may resolve withantibiotic therapyPatient with larger abscesses or those whofalls to improve with antibiotics shouldundergo CT guided percutaneous drainageColonic resection is indicated for those whodevelop either recurrent diverticulitis oranother abscess
  60. 60. CT- GUIDED DRAINAGE OF DIVERTICULAR ABSCESS: Patient with abscess larger than or equal to 4 cmcan be managed with CT guided abscess drainagefollowed by elective surgery after resolution.
  61. 61. Complicated Diverticulitis: Fistulas Occurs in up to 80% of cases requiring surgery Major types  Colovesical fistula 65%  Colovaginal 25%  Coloenteric, colouterine 10%
  63. 63. Complicated Diverticulitis: Fistulas –Symptoms-  Passage of gas and stool from the affected organ  Colovesical fistula:  pneumaturia, dysuria, fecaluria  50% of patients can have diarrhoea and passage of urine per rectum
  64. 64. Complicated Diverticulitis: Fistulas Diagnosis  CT: thickened bladder with associated colonic diverticuli adjacent and air in the bladder  BE: direct visualization of fistula track only occurs in 20-26% of cases  Flexible sigmoidoscopy is low yield (0-3%)  Some argue cystoscopy helpful
  65. 65. Complicated Diverticulitis: Treatment of colovesical Fistulas  Two Approach to treat colovesical fistula 1.Conservative: Without bowel resection by closing the fistula and interposing omentum between bowel and bladder. 2.Conventional: Pinching off the affected bowel from the bladder, resect the sigmoid and perform end to end anastomosis.  Bladder hole is left open and put urethral catheter for free drainage
  66. 66. Treatment of Complicated Diverticulitis:Withgeneralised peritonitis Surgery is principally directed to control sepsis in the peritoneum and circulation. Vigorous resuscitation and antibiotic therapy is still warranted. Opoid analgesia. Oxygen therapy. Urinary catheter to assess hourly urine out put Resection of sigmoid colon and colorectal anastomosis Primary resection and anastomosis after on table lavage in selected case. Hartman’s procedure : Resection of sigmoid colon with formation of end colostomy when condition do not favour primary anastomosis
  67. 67. Treatment of Complicated Diverticulitis:Withobstruction/stricture Symptoms: pain,increasing constipation, passage of ribbon like stools However majority of patient presents with classic symptoms of large bowel obstruction Diagnosis is confirmed by ; patient’s history, physical examinations and radiological confirmation either by contrast enema or CT with oral/rectal contrast
  68. 68. Treatment of Complicated Diverticulitis:With obstruction/stricture Conservative approach: Metallic stents to releive colonic obstruction. Endoluminal wall stents: shown to be safe and effective in decompressing obstruction Surgery: Hartman’s resection and resection with primary anastomosis rarely with loop ostomy is the procedure of choice.[Hartmann procedure is two stage procedure includes-  Colostomy  Sigmoid resection  Rectal stump  3 months later  colostomy takedown and colorectal anastomosis
  69. 69. Diverticular bleeding:Symptoms Most only have symptoms of bloating and diarrhea but no significant abdominal pain  Painless hematochezia  Start – stop pattern; “water faucet” Diverticulitis rarely causes bleeding
  70. 70. Diverticular bleeding:Management Most common cause of brisk hematochezia (30-50% of cases) 15% of patients with diverticulosis will bleed 75% of diverticular bleeding stops without need for intervention Patients requiring less than 4 units of PRBC/ day  99% will stop bleeding Risk of rebleeding  14-38%
  71. 71. Diverticular bleeding:Management Resuscitation Localization Supportive care with blood products
  72. 72. 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
  73. 73. Diverticular bleeding:LocalizationColonoscopy after rapid prepration  Can localize site of bleeding  Offers possible therapeutic intervention (cautery, clip, etc)
  74. 74. Diverticular bleeding:Management ( Cauterization )
  75. 75. Diverticular bleeding:Management A site of active bleeding  Treated successfully with was identified placement of two hemoclips
  76. 76. 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%)
  77. 77. THANK- YOU