Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
This document provides an overview of diverticular disease of the colon, including its anatomy, epidemiology, pathogenesis, diagnosis, and treatment. It describes the typical presentation of uncomplicated and complicated diverticulitis and reviews treatment approaches including antibiotics, abscess drainage, fistula repair, and surgery. Recurrent diverticulitis is noted to increase the risk of complications, with younger patients and more severe initial attacks posing higher risks.
This document provides guidelines for the diagnosis and treatment of diverticulitis and diverticular disease. It discusses classifications of diverticulitis severity including the Hinchey and Ambrosetti classifications. CT scan is the primary diagnostic tool. It recommends antibiotics only for complicated cases and considers outpatient treatment for uncomplicated diverticulitis. For abscesses it recommends percutaneous drainage or antibiotics. It provides guidance on elective resection and discusses primary anastomosis versus Hartmann's procedure.
Diverticulitis is one of the most common gastrointestinal disorders requiring hospitalization in the US, with 50% of individuals developing diverticulosis by age 60. For uncomplicated diverticulitis (Stage 0-1a), outpatient treatment with oral antibiotics and a low-fiber diet is usually adequate. For complicated diverticulitis (Stage 1b or higher), segmental resection is typically recommended 4-6 weeks after the episode to prevent recurrence. Younger patients under age 50 may not necessarily require resection after a single episode of diverticulitis. Immunocompromised individuals have a higher risk of perforation and sepsis from diverticulitis, so elective resection is often recommended after the first episode
Acute Diverticulitis is an inflammation of diverticula in the large intestine that commonly occurs in the sigmoid colon. It presents with lower abdominal pain, fever, and changes in bowel habits. Diagnosis is made through CT scan findings and blood tests. Treatment depends on severity and complications, ranging from oral antibiotics for uncomplicated cases to emergency surgery for perforated diverticulitis with peritonitis. Long term risks include recurrence requiring further treatment or surgery.
Diverticular disease is common in Western populations, increasing with age. It occurs when high intraluminal pressures cause herniation of the colonic mucosa through the muscular wall, typically at arterial branch points. Complications include bleeding, obstruction, inflammation (diverticulitis), and fistula formation. Acute diverticulitis presents with abdominal pain and tenderness, and is managed with resuscitation, antibiotics, and sometimes surgery for perforation or abscess. Elective resection after an attack may not be needed in all cases. Duodenal and jejunal diverticula can also occur and may cause malabsorption.
Surgical Management Of Diverticular DiseaseReda Hussein
This document summarizes the surgical management of diverticular disease based on a literature review. It describes different stages of diverticular abscesses and appropriate treatment approaches. For smaller abscesses, antibiotics or CT-guided drainage may be sufficient, while larger abscesses often require drainage followed by elective surgery. The document also discusses approaches to acute diverticulitis, obstruction, and fistulas, noting debates around conservative versus operative management.
Peptic ulcer disease is caused by acid-pepsin aggression and most commonly affects the duodenum. Helicobacter pylori infection, smoking, NSAIDs, and stress are major risk factors. Patients typically experience episodic epigastric pain relieved by food or antacids. Perforated ulcers present suddenly with generalized abdominal pain and peritonitis. Diagnosis is usually made through chest x-rays showing free air or CT scans detecting free air or fluid. Complications include peritonitis, infection, hypotension, and respiratory failure. Surgical treatments include omental patch, vagotomy, and antrectomy, but carry risks of recurrence or side effects.
This document discusses intestinal obstruction, including its causes, classifications, symptoms, diagnosis and treatment. Some key points:
- Intestinal obstruction can be caused by adhesions, hernias, tumors, strictures and more. It is classified by the obstructed site and presence of blood flow issues.
- Symptoms include pain, vomiting, constipation and distension. Signs depend on obstruction location and duration. Strangulated obstructions require urgent surgery to prevent tissue death.
- Diagnosis involves medical history, physical exam, imaging like x-rays and CT scans. Treatment involves resuscitation, nasogastric drainage, and surgery to relieve the obstruction and address the underlying cause. S
This document provides an overview of diverticular disease of the colon, including its anatomy, epidemiology, pathogenesis, diagnosis, and treatment. It describes the typical presentation of uncomplicated and complicated diverticulitis and reviews treatment approaches including antibiotics, abscess drainage, fistula repair, and surgery. Recurrent diverticulitis is noted to increase the risk of complications, with younger patients and more severe initial attacks posing higher risks.
This document provides guidelines for the diagnosis and treatment of diverticulitis and diverticular disease. It discusses classifications of diverticulitis severity including the Hinchey and Ambrosetti classifications. CT scan is the primary diagnostic tool. It recommends antibiotics only for complicated cases and considers outpatient treatment for uncomplicated diverticulitis. For abscesses it recommends percutaneous drainage or antibiotics. It provides guidance on elective resection and discusses primary anastomosis versus Hartmann's procedure.
Diverticulitis is one of the most common gastrointestinal disorders requiring hospitalization in the US, with 50% of individuals developing diverticulosis by age 60. For uncomplicated diverticulitis (Stage 0-1a), outpatient treatment with oral antibiotics and a low-fiber diet is usually adequate. For complicated diverticulitis (Stage 1b or higher), segmental resection is typically recommended 4-6 weeks after the episode to prevent recurrence. Younger patients under age 50 may not necessarily require resection after a single episode of diverticulitis. Immunocompromised individuals have a higher risk of perforation and sepsis from diverticulitis, so elective resection is often recommended after the first episode
Acute Diverticulitis is an inflammation of diverticula in the large intestine that commonly occurs in the sigmoid colon. It presents with lower abdominal pain, fever, and changes in bowel habits. Diagnosis is made through CT scan findings and blood tests. Treatment depends on severity and complications, ranging from oral antibiotics for uncomplicated cases to emergency surgery for perforated diverticulitis with peritonitis. Long term risks include recurrence requiring further treatment or surgery.
Diverticular disease is common in Western populations, increasing with age. It occurs when high intraluminal pressures cause herniation of the colonic mucosa through the muscular wall, typically at arterial branch points. Complications include bleeding, obstruction, inflammation (diverticulitis), and fistula formation. Acute diverticulitis presents with abdominal pain and tenderness, and is managed with resuscitation, antibiotics, and sometimes surgery for perforation or abscess. Elective resection after an attack may not be needed in all cases. Duodenal and jejunal diverticula can also occur and may cause malabsorption.
Surgical Management Of Diverticular DiseaseReda Hussein
This document summarizes the surgical management of diverticular disease based on a literature review. It describes different stages of diverticular abscesses and appropriate treatment approaches. For smaller abscesses, antibiotics or CT-guided drainage may be sufficient, while larger abscesses often require drainage followed by elective surgery. The document also discusses approaches to acute diverticulitis, obstruction, and fistulas, noting debates around conservative versus operative management.
Peptic ulcer disease is caused by acid-pepsin aggression and most commonly affects the duodenum. Helicobacter pylori infection, smoking, NSAIDs, and stress are major risk factors. Patients typically experience episodic epigastric pain relieved by food or antacids. Perforated ulcers present suddenly with generalized abdominal pain and peritonitis. Diagnosis is usually made through chest x-rays showing free air or CT scans detecting free air or fluid. Complications include peritonitis, infection, hypotension, and respiratory failure. Surgical treatments include omental patch, vagotomy, and antrectomy, but carry risks of recurrence or side effects.
This document discusses intestinal obstruction, including its causes, classifications, symptoms, diagnosis and treatment. Some key points:
- Intestinal obstruction can be caused by adhesions, hernias, tumors, strictures and more. It is classified by the obstructed site and presence of blood flow issues.
- Symptoms include pain, vomiting, constipation and distension. Signs depend on obstruction location and duration. Strangulated obstructions require urgent surgery to prevent tissue death.
- Diagnosis involves medical history, physical exam, imaging like x-rays and CT scans. Treatment involves resuscitation, nasogastric drainage, and surgery to relieve the obstruction and address the underlying cause. S
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
Enterocutaneous fistulae represent catastrophic complications from abdominal diseases and surgeries that can have high mortality. They occur when the bowel is damaged and connects to the skin. Most occur after surgery, especially for inflammatory bowel disease. Prevention focuses on preoperative optimization and careful surgical technique. Management involves nutritional support, identifying the fistula using imaging, treating any infection or obstruction, and eventually closing the fistula to restore bowel continuity. While serious, modern strategies have reduced mortality to 10-20% with proper management.
The document discusses diverticulosis, diverticulitis, and diverticular disease. It summarizes classifications of diverticulitis severity. Ambulatory treatment of uncomplicated acute diverticulitis is shown to be safe and effective. Guidelines recommend a high-fiber diet to prevent diverticulitis recurrence, and discuss evidence for antibiotics, probiotics, and mesalazine. Surgical decisions should be individualized based on severity and recurrence risk.
Information about Inflammatory Bowel Disease by Dr Dhaval Mangukiya.
Details of brief overview of the talk, Surgery in crohn's disease, Scenarios, Localised ileal or ileocaecal disease, Coincidental ileitis, Localised or multifocal colonic disease, Concomitant abscess, Surgical considerations, Anastomotic technique, Laparoscopy etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
This document discusses hiatal hernia, including its types and management. It defines a hiatal hernia as the stomach protruding through the diaphragm into the chest. The main types are sliding (type I), paraesophageal (type II), and combined (type III). Type I is most common and usually asymptomatic, while types II and III can cause pain, satiety, and dysphagia. Diagnosis involves imaging like barium swallow or CT scan. Treatment depends on symptoms, with proton pump inhibitors for mild reflux and surgery to repair large or symptomatic hernias.
Massive lower gastrointestinal bleeding is a life-threatening condition defined by transfusing at least 4 units of blood in 24 hours, hemodynamic instability, or a hematocrit of less than 6g/dl. The main causes are diverticulosis (60%), unknown (13%), hemorrhoids (11%), and neoplasia (9%). Management involves resuscitation, risk assessment, blood transfusions, endoscopy for diagnosis and treatment, and angiography for patients with ongoing bleeding or when endoscopy fails to identify the source. Colonoscopy has high sensitivity but requires bowel preparation, while angiography can localize active bleeding but the patient must be stable. Endoscopic treatments include clips, thermal coagulation, and injections.
Controversies in diverticular disease and diverticulitis conference presentationDr Edward Fitzgerald
This document discusses several controversies and areas of ongoing debate in the treatment of diverticular disease. It summarizes recent evidence questioning traditional practices like routine antibiotics for uncomplicated diverticulitis, prophylactic resection after a single attack, and the natural history assumptions of disease progression. The role of laparoscopic versus open surgery and conservative management of complicated diverticulitis are also addressed. Overall, the treatment paradigm is shifting to a more conservative approach with many prior standards now being re-examined based on emerging evidence.
Large bowel obstruction power point (3)Todd Peterson
(1) 78 year old white female presents with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. She has a history of chronic constipation.
(2) X-ray findings include dilated colon over 6cm, effacement of haustrae peripherally located, and multiple air fluid levels consistent with large bowel obstruction.
(3) Treatment includes IV fluids, analgesics, NG tube, antibiotics, and surgery consult with emergency laparotomy if signs of peritonitis, free air, or sepsis are present.
This document summarizes information about carcinoma of the gallbladder. It discusses that carcinoma of the gallbladder is rare but more common in females. Risk factors include chronic inflammation from gallstones. It spreads early through lymphatics and blood vessels due to the gallbladder's anatomy. Surgical resection is the main treatment but prognosis is poor due to late stage at presentation. Adjuvant chemotherapy may improve outcomes for high-risk patients but targeted therapies have limited effectiveness for this cancer.
This document discusses the management of enterocutaneous fistulas. It begins by defining a fistula and classifying enterocutaneous fistulas. Common causes include postoperative complications, malignancy, and abdominal sepsis. Treatment is divided into five phases: initial recognition and stabilization, investigation of the fistula, decision on operative vs non-operative management, definitive therapy such as surgery or stoma creation, and finally the healing phase. Factors that influence treatment decisions and likelihood of spontaneous closure are also outlined.
Portal hypertension is high blood pressure in the portal vein system that supplies blood to the liver. It has various clinical manifestations that may require surgical management. The surgical approach depends on factors like the underlying liver disease severity and venous anatomy. The main goals of surgery are to decrease portal pressure and prevent complications by bypassing resistance sites or directly treating complications. Procedures include devascularization to reduce variceal blood flow or decompression procedures to reduce portal pressure while maintaining hepatic blood flow. Selective shunts only decompress the variceal compartment while non-selective or partial shunts provide complete or incomplete decompression of the entire portal system. The distal splenorenal shunt is a commonly used selective shunt that
Gallstones are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis refers to gallstones in the gallbladder, while choledocholithiasis refers to gallstones in the common bile duct. Treatment depends on whether gallstones are asymptomatic or symptomatic. Asymptomatic gallstones may be managed expectantly, while symptomatic gallstones usually require surgical removal of the gallbladder (cholecystectomy) or other interventions if complications occur.
The document discusses open abdomen techniques and management. It defines open abdomen as requiring temporary abdominal closure after laparotomy when the skin and fascia cannot be primarily closed. Common causes for open abdomen include necrotizing fasciitis, severe bowel edema, peritonitis, and gross abdominal contamination. Temporary abdominal closure techniques discussed include simple packing, skin closure, Bogota bag, mesh, and Wittmann patch. More recently, negative pressure wound therapy including vacuum-assisted closure and variants like AB Thera have gained popularity due to advantages like improved drainage and wound contraction allowing higher rates of fascial reapproximation. The main goal of open abdomen treatment remains achieving definitive abdominal wall closure, preferably within 8 days to reduce complications.
1) The acute abdomen refers to a clinical situation requiring immediate diagnosis and treatment for an acute change in the intraabdominal organs, usually related to inflammation or infection.
2) A history, physical exam, and serial exams are more important for diagnosis than tests. Common causes include appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated ulcer, and inflammatory bowel disease.
3) CT scans accurately diagnose many conditions like appendicitis, diverticulitis, and pancreatitis but should only be used after developing a working diagnosis, as treatment may involve antibiotics, drainage, or surgery.
This case presentation describes a 34-year-old female patient who presented with right upper quadrant pain. She had a history of epigastric pain radiating to the back for 6 days along with jaundice. Imaging showed choledocholithiasis and cholecystolithiasis. She underwent open cholecystectomy with intraoperative cholangiogram, common bile duct exploration, and T-tube placement. Her postoperative course was uncomplicated and she was discharged with a T-tube in place.
Diverticulosis and diverticular diseaseDoha Rasheedy
This document discusses diverticular disease, specifically diverticulosis and acute diverticulitis. It covers the epidemiology, pathophysiology, clinical presentation, investigations including CT and barium enema, differential diagnosis, and Hinchey classification of diverticulitis severity. Diverticulosis is asymptomatic protrusions in the colon wall that become symptomatic as diverticulitis in 20% of cases from obstruction, inflammation, or perforation. Risk factors include low fiber diet and increased age. CT is the best imaging method to diagnose and stage diverticulitis.
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Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
Biliary stricture is an abnormal narrowing of the bile duct. The most common cause is injury during cholecystectomy, accounting for 80% of non-malignant strictures. Bile duct injury can cause inflammation, fibrosis, scarring, and cirrhosis. Surgical treatment depends on when the injury is recognized, with immediate repair during surgery or delayed repair weeks later being options. Roux-en-Y hepaticojejunostomy is a common repair method that involves a mucosa-to-mucosa anastomosis of the bile duct to the jejunum. Factors like multiple prior repairs, proximal strictures, and surgeon inexperience can lead to poor outcomes.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
Enterocutaneous fistulae represent catastrophic complications from abdominal diseases and surgeries that can have high mortality. They occur when the bowel is damaged and connects to the skin. Most occur after surgery, especially for inflammatory bowel disease. Prevention focuses on preoperative optimization and careful surgical technique. Management involves nutritional support, identifying the fistula using imaging, treating any infection or obstruction, and eventually closing the fistula to restore bowel continuity. While serious, modern strategies have reduced mortality to 10-20% with proper management.
The document discusses diverticulosis, diverticulitis, and diverticular disease. It summarizes classifications of diverticulitis severity. Ambulatory treatment of uncomplicated acute diverticulitis is shown to be safe and effective. Guidelines recommend a high-fiber diet to prevent diverticulitis recurrence, and discuss evidence for antibiotics, probiotics, and mesalazine. Surgical decisions should be individualized based on severity and recurrence risk.
Information about Inflammatory Bowel Disease by Dr Dhaval Mangukiya.
Details of brief overview of the talk, Surgery in crohn's disease, Scenarios, Localised ileal or ileocaecal disease, Coincidental ileitis, Localised or multifocal colonic disease, Concomitant abscess, Surgical considerations, Anastomotic technique, Laparoscopy etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Seminar presentation by 5th-year medical students under the supervision of in house lecturer. He was previously working as a consultant surgeon in Syria. Reference as mentioned in the slides.
This document discusses hiatal hernia, including its types and management. It defines a hiatal hernia as the stomach protruding through the diaphragm into the chest. The main types are sliding (type I), paraesophageal (type II), and combined (type III). Type I is most common and usually asymptomatic, while types II and III can cause pain, satiety, and dysphagia. Diagnosis involves imaging like barium swallow or CT scan. Treatment depends on symptoms, with proton pump inhibitors for mild reflux and surgery to repair large or symptomatic hernias.
Massive lower gastrointestinal bleeding is a life-threatening condition defined by transfusing at least 4 units of blood in 24 hours, hemodynamic instability, or a hematocrit of less than 6g/dl. The main causes are diverticulosis (60%), unknown (13%), hemorrhoids (11%), and neoplasia (9%). Management involves resuscitation, risk assessment, blood transfusions, endoscopy for diagnosis and treatment, and angiography for patients with ongoing bleeding or when endoscopy fails to identify the source. Colonoscopy has high sensitivity but requires bowel preparation, while angiography can localize active bleeding but the patient must be stable. Endoscopic treatments include clips, thermal coagulation, and injections.
Controversies in diverticular disease and diverticulitis conference presentationDr Edward Fitzgerald
This document discusses several controversies and areas of ongoing debate in the treatment of diverticular disease. It summarizes recent evidence questioning traditional practices like routine antibiotics for uncomplicated diverticulitis, prophylactic resection after a single attack, and the natural history assumptions of disease progression. The role of laparoscopic versus open surgery and conservative management of complicated diverticulitis are also addressed. Overall, the treatment paradigm is shifting to a more conservative approach with many prior standards now being re-examined based on emerging evidence.
Large bowel obstruction power point (3)Todd Peterson
(1) 78 year old white female presents with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. She has a history of chronic constipation.
(2) X-ray findings include dilated colon over 6cm, effacement of haustrae peripherally located, and multiple air fluid levels consistent with large bowel obstruction.
(3) Treatment includes IV fluids, analgesics, NG tube, antibiotics, and surgery consult with emergency laparotomy if signs of peritonitis, free air, or sepsis are present.
This document summarizes information about carcinoma of the gallbladder. It discusses that carcinoma of the gallbladder is rare but more common in females. Risk factors include chronic inflammation from gallstones. It spreads early through lymphatics and blood vessels due to the gallbladder's anatomy. Surgical resection is the main treatment but prognosis is poor due to late stage at presentation. Adjuvant chemotherapy may improve outcomes for high-risk patients but targeted therapies have limited effectiveness for this cancer.
This document discusses the management of enterocutaneous fistulas. It begins by defining a fistula and classifying enterocutaneous fistulas. Common causes include postoperative complications, malignancy, and abdominal sepsis. Treatment is divided into five phases: initial recognition and stabilization, investigation of the fistula, decision on operative vs non-operative management, definitive therapy such as surgery or stoma creation, and finally the healing phase. Factors that influence treatment decisions and likelihood of spontaneous closure are also outlined.
Portal hypertension is high blood pressure in the portal vein system that supplies blood to the liver. It has various clinical manifestations that may require surgical management. The surgical approach depends on factors like the underlying liver disease severity and venous anatomy. The main goals of surgery are to decrease portal pressure and prevent complications by bypassing resistance sites or directly treating complications. Procedures include devascularization to reduce variceal blood flow or decompression procedures to reduce portal pressure while maintaining hepatic blood flow. Selective shunts only decompress the variceal compartment while non-selective or partial shunts provide complete or incomplete decompression of the entire portal system. The distal splenorenal shunt is a commonly used selective shunt that
Gallstones are concretions that form in the biliary tract, usually in the gallbladder. Cholelithiasis refers to gallstones in the gallbladder, while choledocholithiasis refers to gallstones in the common bile duct. Treatment depends on whether gallstones are asymptomatic or symptomatic. Asymptomatic gallstones may be managed expectantly, while symptomatic gallstones usually require surgical removal of the gallbladder (cholecystectomy) or other interventions if complications occur.
The document discusses open abdomen techniques and management. It defines open abdomen as requiring temporary abdominal closure after laparotomy when the skin and fascia cannot be primarily closed. Common causes for open abdomen include necrotizing fasciitis, severe bowel edema, peritonitis, and gross abdominal contamination. Temporary abdominal closure techniques discussed include simple packing, skin closure, Bogota bag, mesh, and Wittmann patch. More recently, negative pressure wound therapy including vacuum-assisted closure and variants like AB Thera have gained popularity due to advantages like improved drainage and wound contraction allowing higher rates of fascial reapproximation. The main goal of open abdomen treatment remains achieving definitive abdominal wall closure, preferably within 8 days to reduce complications.
1) The acute abdomen refers to a clinical situation requiring immediate diagnosis and treatment for an acute change in the intraabdominal organs, usually related to inflammation or infection.
2) A history, physical exam, and serial exams are more important for diagnosis than tests. Common causes include appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated ulcer, and inflammatory bowel disease.
3) CT scans accurately diagnose many conditions like appendicitis, diverticulitis, and pancreatitis but should only be used after developing a working diagnosis, as treatment may involve antibiotics, drainage, or surgery.
This case presentation describes a 34-year-old female patient who presented with right upper quadrant pain. She had a history of epigastric pain radiating to the back for 6 days along with jaundice. Imaging showed choledocholithiasis and cholecystolithiasis. She underwent open cholecystectomy with intraoperative cholangiogram, common bile duct exploration, and T-tube placement. Her postoperative course was uncomplicated and she was discharged with a T-tube in place.
Diverticulosis and diverticular diseaseDoha Rasheedy
This document discusses diverticular disease, specifically diverticulosis and acute diverticulitis. It covers the epidemiology, pathophysiology, clinical presentation, investigations including CT and barium enema, differential diagnosis, and Hinchey classification of diverticulitis severity. Diverticulosis is asymptomatic protrusions in the colon wall that become symptomatic as diverticulitis in 20% of cases from obstruction, inflammation, or perforation. Risk factors include low fiber diet and increased age. CT is the best imaging method to diagnose and stage diverticulitis.
Hallo, Welkom op onze site!Laptop Accu voor ,Laptop accu's voor een lage prijs door directe import.Verkoop van Accu Laptop,Batterij,Laptop laders,Adapter.HomeAcerAsusAppleDellHP/CompaqSonyLenovo/IBMToshibaFujitsuSamsungzoekenLage prijs, 1 jaar garantie
Certificering PSE, snel reageren
Hot Items
Accu VGP-BPS23,
Accu VGP-BPS23/W
Accu aspire one a110,
Accu aspire one d250
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The document outlines the roles and responsibilities of a hemodialysis nurse. The nurse administers safe nursing care to patients receiving hemodialysis treatments using proper procedures and knowledge of end-stage renal disease (ESRD) and its treatment. Key duties include delivering nursing care via the nursing process, practicing according to standards and guidelines, initiating and revising patient care plans, assisting with patient goals, and accurately documenting care. The nurse must also maintain competence in all dialysis procedures and skills.
Dokumen ini merupakan perlembagaan untuk Persatuan Puteri Islam di Sekolah Menengah Agama Irsyadiah yang mengatur penubuhan, matlamat, keahlian, aktiviti, dan peraturan organisasi tersebut untuk memupuk semangat bertanggungjawab di kalangan pelajar perempuan sekolah.
Large bowel obstruction is an emergent condition that requires prompt surgical intervention. It can result from infectious, inflammatory, neoplastic, or mechanical causes such as volvulus or incarcerated hernia. Symptoms include abdominal pain, distention, nausea, vomiting, and constipation. Diagnosis involves physical exam, imaging studies like CT scan, and lab tests. Treatment involves resuscitation, nasogastric decompression, and surgical resection of the obstructing lesion with proximal diversion such as colostomy. Complications can include perforation, sepsis, and death if not treated early. Prognosis depends on the underlying cause, with cancer outcomes varying based on the specific carcinoma.
FleetCor Technologies will acquire Comdata for an undisclosed sum. Comdata is a provider of commercial card programs and payment processing services to businesses in over 40 countries. The acquisition will expand FleetCor's existing portfolio of fuel, lodging, and other commercial card programs and services.
The Kompas Jelajah Sepeda cycling event has been held several times since 2008 to promote healthy living and tourism in Indonesia. In 2013, the Kompas Bali Bike event was part of this and brought together participants from several countries to cycle around the island of Bali over 3 days, passing scenery and stopping in different cities. The document provides background information on the event, including its objectives, timeline, participant demographics, and results.
Opthalmology market an oppertunity and overview 1Ishan Shukla
This document discusses the ophthalmology market. It states that the global ophthalmic drugs market is expected to reach $18.7 billion by 2022, driven by an aging population and increasing rates of eye disorders. The market is segmented by disease, with glaucoma being the largest segment at over $5 billion in 2008. Growth in the market will come from treatments for diabetic retinopathy, as there are currently no approved drugs and several treatments are in the pipeline. Generic drugs are also expected to gain market share due to patent expiries of major brands like Xalatan. The top 10 ophthalmic products by sales are also listed.
The document advertises car detailing services from Capital AutoSpa. It lists several detail packages including exterior-only, exterior and interior, and premium packages that include interior steam cleaning and leather treatment. Additional a la carte services are offered such as interior shampooing and odor removal. Capital AutoSpa prides itself on its customer service through complimentary services and being available 24/7. The business also notes its ecofriendly waterless carwash technology that saves water and leaves a protective finish on vehicles.
ANTOLOGI SEJADAH RINDU:PUISI TRADISIONAL: BERBUAT ISTANA ZAMAN DAHULUNormarjana Ibrahim
- Sultan memerintahkan empat orang besar dan 44 tukang rumah untuk membina sebuah istana megah dalam masa tujuh bulan.
- Istana ini dibina dengan seni bina tradisional Melayu yang indah, menggunakan unsur-unsur alam sebagai hiasan.
- Selepas siap, tiada sesiapa yang dapat meniru keindahan istana ini selain empat puluh empat tukang yang membinanya.
Diverticulitis: Popular Misconceptions & New Management rev 2019Patricia Raymond
As presented at RMSGNA 2019: Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!
Lower GI bleeding can result from various causes in the colon and rectum. The most common etiologies are diverticular disease, which accounts for 60% of cases, and inflammatory bowel disease, which causes 13% of cases. Diverticulosis is characterized by outpouchings in the colon wall that are prone to bleeding. It is usually asymptomatic but can lead to complications like diverticulitis, abscesses, fistulas, and obstruction. Inflammatory bowel disease includes both Crohn's disease and ulcerative colitis, which cause transmural and mucosal inflammation respectively. Common symptoms of lower GI bleeding include hematochezia and melena. Treatment depends on the underlying cause but may involve medications, surgery
science has an evolving nature. what happened today may not be tomorrow, what is not today may happen tomorrow.
No one is complete so reading and thinking may open the door to the hidden ground.
Complicated diverticular disease
Diverticulitis is the most usual clinical complication of
diverticular disease, affecting 10–25% of patients with
diverticular.
The process by which diverticulitis arises has been likened to that of appendicitis, with a diverticulum becoming obstructed by inspissated stool in its neck.
This faecalith abrades the mucosa of the sac, causing inflammation and expansion of usual bacterial flora, with
diminished venous outflow and localised ischaemia.
Bacteria may breach the mucosa and extend the process
through the full wall thickness, ultimately leading to
perforation.
This document discusses lower gastrointestinal bleeding (LGIB), which occurs in the small and large intestines, presenting as hematochezia or melaena. Common causes of LGIB include diverticular disease, inflammatory bowel diseases like Crohn's disease and ulcerative colitis, ischemic colitis, vascular malformations, polyps, tumors, and anal issues. LGIB is typically chronic and self-limiting, though some cases are acute and require blood transfusion. The diagnostic workup depends on the patient's age and symptoms, and may involve endoscopy, imaging, or angiography to identify the source of bleeding.
Choledochal cyst is a rare congenital abnormality of the bile ducts that can cause bile duct dilation. It occurs more commonly in Asia. Imaging such as ultrasound, CT, MRI and MRCP are used to diagnose choledochal cysts and characterize the type. The main types are dilation of the extrahepatic bile ducts, diverticula, intramural duodenal dilation, or multiple cysts. Surgical resection is the primary treatment to prevent complications like cholangitis, stones and cancer. Resection involves removing the cyst and reconstructing bile flow with Roux-en-Y hepaticojejunostomy.
This document summarizes a seminar on choledochal cysts. It discusses the presentation, incidence, classification, investigations, complications and management of choledochal cysts. The key points are:
1. Choledochal cysts are bile duct abnormalities that can occur anywhere in the biliary tree. Complete excision of extrahepatic cysts is the standard treatment.
2. They are most common in children but can sometimes be diagnosed in adults. Complications include biliary stones, pancreatitis and malignancy.
3. Investigations include ultrasound, CT, MRCP and ERCP to characterize the cyst type and rule out complications. Surgical excision and Roux-en
Diverticular disease is common in Western populations, where diverticula form as outpouchings in the colonic wall. Diverticulosis refers to the presence of diverticula without inflammation, while diverticulitis occurs when diverticula become inflamed. Common symptoms of diverticulitis include severe left lower quadrant pain, fever, and leukocytosis. Complications can include abscess, fistula formation, perforation, hemorrhage, or obstruction. Diagnosis involves imaging such as CT scan or contrast enema to evaluate for complications. Treatment depends on severity but may involve antibiotics, drainage, or surgical resection.
Choledochal cysts are dilations of the common bile duct. They are most commonly diagnosed in children under 10 years old and can present with abdominal pain, jaundice, or mass. Imaging like ultrasound, CT, MRCP, and cholangiography are used to diagnose and characterize the cyst type. Complete surgical excision and biliary-enteric anastomosis is the treatment of choice to prevent complications like cholangitis, pancreatitis, and cholangiocarcinoma. Long term follow up is needed due to risk of recurrent issues and malignancy.
The document discusses lower gastrointestinal bleeding, including its definition, causes such as diverticular disease, inflammatory bowel disease, angiodysplasia, and coagulopathy. It covers the clinical presentation, various diagnostic tests including colonoscopy, capsule endoscopy and nuclear scintigraphy. Colonoscopy is the mainstay for evaluation as it can both diagnose the bleeding source and provide therapeutic treatment in many cases.
This document provides an overview of lower gastrointestinal bleeding and colorectal diseases. It discusses lower GI bleed, colorectal cancer, diverticular disease, inflammatory bowel disease, and hemorrhoids. For colorectal cancer, it covers epidemiology, pathology, staging, risk factors, screening and treatment. It also discusses complications, investigations, and management for diverticular disease and inflammatory bowel diseases like ulcerative colitis.
1. The patient presented with symptoms of bowel obstruction including vomiting, abdominal pain and distension, and absent bowel sounds. This suggests sigmoid volvulus, which was confirmed with x-ray and gastrografin enema showing a twisted colon.
2. Sigmoid volvulus occurs when the sigmoid colon twists around its blood supply and can lead to strangulation or perforation if not treated. It most commonly affects the sigmoid colon and risks include chronic constipation.
3. For an uncomplicated case, endoscopic detorsion can be attempted but surgery is needed for gangrenous or perforated bowel. Recurrence risk is high so elective surgery is recommended after recovery.
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
- Choledochal cysts are rare congenital abnormalities of the biliary tract that can cause complications like pancreatitis and cholangitis if not treated.
- They are usually diagnosed in children under 10 years old and present with symptoms like abdominal pain, jaundice, and mass. Investigation with ultrasound, CT, MRCP and ERCP can help characterize the cyst type and anatomy.
- The standard treatment is complete surgical excision of the cyst along with biliary-enteric drainage (e.g. Roux-en-Y hepaticojejunostomy) to prevent future complications. The surgical approach depends on the specific cyst type but aims to remove the entire cyst while preserving the biliary
Diverticular disease is a common condition where pouches called diverticula bulge out from the colon wall, usually where blood vessels penetrate the colon. Diverticulosis is the presence of diverticula without inflammation, while diverticulitis occurs when diverticula become inflamed or infected, usually due to hard stool getting stuck in a diverticulum. Diverticulitis ranges from uncomplicated cases treated with antibiotics to complicated cases involving abscesses, fistulas, or perforation requiring surgery. Risk factors include low-fiber diet, aging, and high blood pressure.
Diverticular disease involves pouches or sacs that protrude from the intestinal wall. Diverticulosis refers to the presence of diverticula without inflammation. Diverticulitis occurs when diverticula become inflamed, usually due to infection. Risk factors include older age and low-fiber diets. Symptoms include abdominal pain, changes in bowel habits, and fever. Treatment depends on severity and may involve antibiotics, drainage of abscesses, or surgery to remove the affected colon segment. Complications can include abscesses, fistulas, obstruction, or generalized peritonitis.
This document discusses acute pancreatitis, including:
- It is a common disease causing significant morbidity and mortality, with over 250,000 US hospital admissions per year and 3,000 deaths.
- The most common causes are gallstone obstruction and alcohol abuse.
- Symptoms include severe abdominal pain, nausea, vomiting, and tenderness. Diagnosis involves blood tests showing elevated lipase, amylase, and imaging studies like CT or MRI.
- Risk stratification systems like Ranson's criteria and the Atlanta classification are used to determine severity and risk of complications like organ failure. Early goal-directed fluid resuscitation is important for severe cases while avoiding excessive fluids.
This document discusses the differential diagnosis and risk factors for an upper gastrointestinal bleed in an HIV-positive patient. Key points include: (1) CMV, HSV, primary HIV ulcers, Kaposi's sarcoma, and lymphoma are more likely causes of ulcers or masses in the GI tract of an HIV+ patient; (2) The patient's CD4 count, esophageal ulcer, varices, gastric polyp, and bluish GEJ lesion suggest diagnoses of gastrointestinal CMV, esophageal varices related to cirrhosis, or Kaposi's sarcoma are most probable; (3) Co-infections like CMV are more common in HIV patients with low CD4 counts and can cause severe
Similar to Diverticulitis: Popular Misconceptions and New Management (20)
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Hash It Out: The Role of Medical Marijuana in GIPatricia Raymond
Marijuana's side effect of Cannabinoid Hyperemesis Syndrome is well known to us, as is use of Marinol to enhance appetite in the chronically ill, but are there other high points in the use of medical marijuana? What about the possible use of CBD oil for chronic pancreatitis or intractable abdominal pain?
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As presented 09/2019 at RMSGNA: In the 50's , doctors recommended smoking for your health. More recently gastroenterologists told patients with ulcers to drink milk and eat bread to heal.
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Examine historical misinformation in dietary management of gastrointestinal disorders
Describe the emerging evidence supporting the primary role of dietary therapies in digestive disease including Irritable Bowel Syndrome, Inflammatory Bowel Disease, Small Intestinal Bacterial Overgrowth, Non-Alcoholic Fatty Liver Disease, Gastroparesis, Pancreatitis, Post-Gastric Bypass, and Diverticulitis.
Identify the role of the Registered Dietitian and the importance of a multi-disciplinary approach to the management of digestives diseases
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Describe the emerging evidence supporting the primary role of Kudo Pit Patterns in visual inspection of in situ polyps, and demonstrate your ability to identify the patterns
Authentication of Kudo Pits
Pits and their risks
Images of Kudo pits
Quiz of Kudo Pits
Discuss the potential and shortcomings of the Paris Polyp Classification, and demonstrate an ability to classify the polyp shape
Polyp shapes and and their risks (pedunculated, elevated, depressed)
Images of polyps for Paris classification
Polyps and their risks
Quiz of polyp shapes
Concerns regarding interobserver variability
Familial Adenomatous Polyposis affects 1 in 10,000 to 30,000 Americans who experience 100% risk of colon cancer, and FAP doesn't end with a total colectomy for removal of their hundreds of polyps.
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Epidemiology and risk factors
Complete and incomplete, types I-III based on mucin expression
Risk of progression to cancer
Proper surveillance and endoscopic mapping
Management
35 min
Meckels
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Who was Meckel
Epidemiology and risk factors
Rule of twos
Risk of bleed
Management
10 min
Pancreatic Rests
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Endoscopic appearance
Anatomic development
Risks for pancreatitis, cancer, obstruction
Endoscopic and surgical management
10 min
The document discusses the visual examination of the belly and navel from anatomical, historical, social, and medical perspectives. Anatomically, the navel is located at the midpoint of the body and develops from the umbilical cord that nourishes the fetus. Historically, many religions and cultures have ascribed spiritual or theological significance to the navel. Medically, examination of the navel can provide clues to intra-abdominal diseases and conditions. Variations in navel appearance like outies can occur normally or indicate issues like hernias.
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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6. Nut and seed concerns are so yesterday…
• Nut, corn, and popcorn consumption are NOT associated with an
increase in risk of diverticulosis, diverticulitis or diverticular bleeding.
• Health Professionals Follow-up Study
> 47,228 men between the ages of 40 and 75 years
> Inverse association between the amount of nut and popcorn consumption
and the risk of diverticulitis (HR nuts 0.8, 95% CI 0.63-1.01; HR popcorn
0.72, 95% CI 0.56-0.92)
> No association between consumption of corn and diverticulitis
> No association between nut, popcorn, or corn consumption and diverticular
bleeding or uncomplicated diverticulosis.
Strate LL, Liu YL, Syngal S, et al.
Nut, corn, and popcorn consumption
and the incidence of diverticular disease.
JAMA 2008; 300:907.
9. What percent of your screening
colonoscopy patients have
diverticulosis?
10. Prevalence of diverticulosis
• Less than 20 percent
at age 40 Increases
to 60 percent by age
60
• Western and
industrialized nations
have prevalence rates
of 5 to 45 percent
• Diverticulosis is
ASYMPTOMATIC!
11. 95 % of patients with diverticula have sigmoid diverticula
Only in sigmoid colon Mainly in sigmoid colon
Thoughout colon Not sigmoid colon
65%
24%
Distribution of Tics
7% 4%
12. It’s about the taenia!
• The taenia coli run the
length of the large
intestine.
• The taenia coli are
shorter than the the
colon
> Gathers (“becomes
sacculated”) forming the
haustra of the colon
— shelf-like intraluminal
projections.
http://salerno.uni-muenster.de/data/bl/sobotta/pics_big/0960.jpg
13.
14. Wall weakness + pressure = diverticulosis
• Weakness in wall where the vasa recta penetrate the circular muscle
layer of the colon.
• Abnormal colonic motility
> Exaggerated segmentation contractions in which segmental muscular
contractions separate the lumen into chambers.
> Increase in intraluminal pressure predisposes to herniation of mucosa and
submucosa.
• Sigmoid colon location
> Laplace’s law according to which pressure (P) is proportional to wall
tension (T) and inversely proportional to bowel radius (R), where k is a
conversion factor (P = kT ÷ R).
— Sigmoid colon is the segment of the colon with the smallest diameter, it
is the site of the highest pressure during segmentation of the colon.
15. Asian (Right sided) diverticulosis
• Prevalence between <1
and 5 per million
population
• Predominantly right-sided
• Increased prevalence with
adoption of more Western
lifestyle.
> Japan has experienced an
increase in the prevalence of
right-sided diverticulosis
similar to the increase in left-sided
diverticula in
westernized countries.
http://wholelifefengshui.com/home/attachment/the-entrance-to-an-asian-temple
17. Grading diverticulitis- Hinchey classification
• Proposed by Hinchey et al. in 1978
• Classifies colonic perforation due to diverticular disease for surgeons.
> Hinchey I - localized abscess (para-colonic)
> Hinchey II - pelvic abscess
> Hinchey III - purulent peritonitis (pus in the abdominal cavity)
> Hinchey IV - feculent peritonitis.
Side Bar: there is NO classification system
for uncomplicated diverticulosis;
the ‘Mild’, ‘Moderate’, ‘Severe’ descriptions
we use endoscopically are not quantitative.
19. Symptomatic uncomplicated diverticular disease (SUDD)
• Persistent abdominal pain
attributed to diverticula in
the absence of
macroscopically overt
colitis or diverticulitis.
• ‘Smouldering
diverticulitis’
• Wall thickening is present
in the absence of
inflammatory changes on
computed tomography
(CT).
• Symptoms overlap with
IBS
> Chronic colicky/Constant
lower abdominal pain
> Pain relieved with
defecation, passage of flatus
> Bloating, distension,
flatulence
> Associated alteration in
bowel habit
• No signs of inflammation (fever,
leukocytosis
20. Segmental colitis associated with diverticula (SCAD)
> “Diverticular colitis”
> Characterized by
inflammation in the
interdiverticular mucosa
without involvement of
the diverticular orifices.
21. What percent of your diverticulosis
patients get diverticulitis?
• How often do people under 50 get
diverticulitis?
• Who gets more diverticulitis, men or
women?
22. Diverticulitis
• 4 to 25 percent of patients with diverticulosis develop diverticulitis.
• Diverticulitis increases with age
> The mean age at admission for acute diverticulitis is 63 years.
> 16 percent of admissions for acute diverticulitis are in patients under 45
years of age.
— right-sided diverticulitis in only 1.5 percent of cases
• Increased incidence of diverticulitis
> Increase in admissions for acute diverticulitis by 26 percent from 1998 to
2005.
> The largest increase was in patients aged 18 to 44 years (82 percent).
23. Under age 50 years
Diverticulitis is more common in men
25. Young obese males & diverticulosis
Virulent diverticular disease in young obese men.
Schauer PR, Ramos R, Ghiatas AA, Sirinek KR Am J Surg. 1992;164(5):443.
• During a 9-year period ending in December 1990, 61 of 238 patients
treated for acute diverticulitis were 40 years of age or younger.
> Primarily obese Hispanic males in whom the correct diagnosis was
frequently missed.
> Younger patients more frequently required an operation on an urgent basis
for complications of diverticulitis during the initial hospitalization.
> The most common indication for operation in young patients was
perforation compared with recurrent disease for the older age group.
> Sevenfold incidence of enteric fistulas complicating their acute episode of
diverticulitis.
26. Between the ages of 50 and 70
Slight female preponderance of diverticulitis
27. Over age 70
Marked female preponderance of diverticulitis
28. Diverticulitis from fecalith? Not.
• Diverticulitis from
micro- or macroscopic
perforation of a
diverticulum.
> Erosion of the
diverticular wall by
increased intraluminal
pressure or inspissated
food particles—Not a
fecalith.
30. Treatment of acute diverticulitis
• Bowel rest
• Antibiotics (?) 10-14
days
> Cipro/Flagyl
> Cipro/Clindamycin
• No colonoscopy x 6
weeks
> Perforation risk
• 20-40% will have
recurrent attacks
> Similar to first attack,
not worse
• 5-20% will get SUDD
AKA “smoldering
diverticulitis”
• Unknown percentage
with SCAD
31. Acute diverticulitis complications in 25%
• Abscess —17% of patients
hospitalized with acute
diverticulitis
• Fistula —between the colon
and adjacent viscera. Fistulas
occur in approximately 20% of
patients with surgically treated
diverticulitis and most
commonly involve the bladder.
• Perforation —1 to 2 percent of
patients with acute diverticulitis
have a perforation with purulent
or fecal peritonitis
> Mortality rates approach 20 %
http://radiology.med.sc.edu/diverticularabscess.htm
32. Antibiotics in question for diverticulitis, 2012
• Multicenter randomized trial of 623 patients
> CT-scan uncomplicated diverticulitis
• No statistical difference in complication rates based upon use of
antibiotics
• No difference in rate of bowel perforation
• Similar rate of recurrent diverticulitis (16.2 versus 15.8 percent).
> 3 patients randomized no antibiotics - intra-abdominal abscess
• If additional studies support, selected patients who are diagnosed
with uncomplicated diverticulitis may be safely managed with close
observation without antibiotic therapy
33. What percent of your diverticulosis
patients bleed?
• What side bleeds?
• How many need intervention to stop?
• What’s the risk of rebleed?
34. Diverticular bleeding—it’s about the Vasa Recta
• The responsible vasa recta drapes over the dome of the
diverticulum
> Covered only with mucosa
> Over time, becomes injured
> Ruptures into lumen, with bleeding
• Diverticular bleeding typically occurs in the absence of
diverticulitis.
35.
36. Diverticular bleeding
• 5 to 15 percent with
diverticulosis
> Massive in a third of
patients
> The right colon is the
source of colonic
diverticular bleeding in
50 to 90 percent of
patients.
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37. “Will I bleed again from my diverticula?”
• Bleeding stops spontaneously
in 75 percent of patients overall
> 99 % transfused < four
units/day
• Risk of rebleeding 14 to 38%
• After second bleeding episode,
risk of further bleed rises to 21
to 50%
• Morbidity and mortality rates
from diverticular bleeding 10 to
20 percent
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38. Management of diverticular bleed
• Colonoscopy
• Scintigraphy
• Angiography
• Surgery
http://www.healio.com/gastroenterology/curbside-consultation/%7Bb6e2c2ea-9e74-499c-b26a-4f79166f6849%7D/when-do-i-need-to-refer-
39. Endoscopic management of diverticular hemorrhage
48 patients with hematochezia and known diverticulosis
• A definite diverticular bleeding source (defined by active bleeding from
a diverticulum, a nonbleeding visible vessel, or an adherent clot)
> Identified in 10 patients (21 %)
> Successful treatment with endoscopic therapy
> Treatment included four-quadrant submucosal injection of epinephrine (1
to 2 mL aliquots, dilution 1:20,000) or endoscopic tamponade.
— Visualized non-bleeding diverticular vessel, the vessel was treated with
bipolar coagulation at a setting of 10 to 15 Watts of power with
moderate l pressure directly on the vessel using one-second pulses
until good coagulation and flattening of the vessel were achieved .
— Nonbleeding adherent clots were injected with epinephrine and shaved
down to 3 to 4 mm above the attachment with a cold polypectomy
snare (without coagulation). The underlying stigmata (usually visible
vessels) were then coagulated with a bipolar probe.
40. • No episodes of recurrent bleeding
> Median follow-up of 30 months
• No patient required emergency surgery
• In a separate group of 17 patients with definite diverticular bleeding who did
NOT receive endoscopic therapy, persistent bleeding after colonoscopy
occurred in nine (53 percent).
• Six with persistent bleeding underwent surgery, and two suffered
complications following surgery.
• EBL and hemoclips are being studied for diverticular bleeding
42. What lifestyle modifications have been
proved to help diverticulosis?
• Avoid nuts and seeds?
• High fiber diet?
• Reduce animal fat and meat?
• Vigorous exercise?
• Weight management?
• Stop smoking?
• Reduce caffeine?
• Stop drinking alcohol?
43. Dietary Fiber- unclear, but good maintenance
• CAUSE: Low dietary fiber predisposes to the development of
diverticular disease- conflicting results
• TREATMENT of Symptomatic: Reduction symptoms in patients with
symptomatic uncomplicated diverticular disease (SUDD) –NO
• PREVENTION of Attacks: Reduction the incidence of symptomatic
diverticular disease –Yes
> By decreasing intestinal inflammation and altering the intestinal microbiota
— Study > 47,000 men
— Adjustment for age, energy-adjusted total fat intake, and physical
activity
— Total dietary fiber intake was inversely associated with the risk of
symptomatic diverticular disease (RR 0.58 highest quintile versus
lowest quintile for fiber intake).
44. Fat and Red Meat—Bad for your diverticula
> Same cohort study as fiber
• High-total-fat, low-fiber
diet the RR 2.35 (95% CI
1.38, 3.98) verses low-total-
fat, high-fiber diet
• High-red-meat, low-fiber
diet RR 3.32 (95% CI
1.46, 7.53) verses low-red-
meat, high-fiber diet.
45. Sedentary lifestyle and Obesity- Bad for your tics
• Vigorous physical activity= reduction in risk of diverticulitis and
diverticular bleeding.
> 8,000 men aged 40 - 75
> Risk of developing symptomatic diverticular disease was inversely related
to overall physical activity (RR 0.63 for highest versus lowest extremes)
after adjustment for age and dietary fat and fiber
> Most of the decrease in risk was associated with vigorous activity such as
jogging and running.
• Obesity = increased risk of diverticulitis and diverticular bleeding.
> 47,228 male health professionals
> 801 incident cases of diverticulitis and 383 cases of diverticular bleeding
during 18 years of follow-up
> Risk of diverticulitis and diverticular bleeding was significantly higher in
those with the highest quintile of waist circumference as compared with the
lowest (RR diverticulitis 1.56, 95% CI 1.18-2.07; RR diverticular bleeding
1.96, 95% CI 1.30-2.97).
46. Cigs- NO, Caffeine and alcohol OK
• Current smokers at
increased risk for
perforated diverticulitis
and a diverticular abscess
as compared with
nonsmokers (OR 1.89,
95% CI 1.15-3.10)
• Caffeine and alcohol are
not associated with an
increased risk for
symptomatic diverticular
disease
47. DIVA Trial Mesalamine (2013)
• 1-year double-blind, randomized, placebo-controlled study
> CT-scan confirmed acute diverticulitis
> placebo, mesalamine, or mesalamine+Bifidobacterium infantis 35624
(Align) for 12 weeks and followed for 9 additional months.
• Global symptom score (GSS) of 10 symptoms (abdominal pain,
abdominal tenderness, nausea/vomiting, bloating, constipation,
diarrhea, mucus, urgency, painful straining, and dysuria). Patients
were required to have a GSS≥12 at baseline, including an abdominal
pain score>2.
• One hundred seventeen patients (placebo, 41; mesalamine, 40;
mesalamine+probiotic, 36)
48. DIVA Trial Mesalamine (2013)
• GSS decreased in all groups during treatment without a statistically
significant difference between mesalamine and placebo, however;
scores were consistently lower for mesalamine at all time points.
• The rate of complete response (GSS=0) was significantly higher with
mesalamine than placebo at weeks 6 and 52 (P<0.05), and was
particularly high for rectosigmoid symptoms at weeks 6, 12, 26, and
52.
• Recurrence of diverticulitis was low and comparable across groups.
• Probiotic in combination with mesalamine did not provide additional
efficacy.
• CONCLUSIONS:
• Mesalamine demonstrated a consistent trend in reducing symptoms.
• Addition of probiotic did not increase mesalamine efficacy.
49. Probiotics, remains unclear
• ClinicalTrials.gov identifier: NCT01609751
• Daily probiotic Lactobacillus casei Shirota (LcS)
• Pilot study investigating whether consumption of once daily probiotic
LcS as Yakult fermented milk would help either prevent attacks of
diverticulitis completely or significantly reduce frequency of reduce of
attacks.
• 12 months, completed November 2013, results pending
• May reduce recurrent symptoms, what strain and how long?