In this ppt presentation I discuss about Diverticulosis, Sigmoid volvulus and Rectal prolapse

1. Diverticulosis, Volvulus
& Rectal Prolapse
Dr.B.Selvaraj MS;Mch; FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia

2.  A . General principles
 l . Colonic diverticula are mucosal outpouchings through the
submucosa and the muscular layer of the colon.
 2 . They occur most commonly in the sigmoid colon, and in 10% of
patients, they involve the entire colon.
 3. They arise between antimesenteric taenia and the mesenteric
taenia at the site of entry of the blood vessels
DIVERTICULOSIS

3.  B . Epidemiology and etiology
 l . Diverticular disease of the colon is an acquired condition.
 2 . This condition is a disorder of modern civilization and is
associated with consumption of refined food products . It is rare in
rural African and Asian populations where dietary fiber is high.
DIVERTICULOSIS

4. DIVERTICULOSIS

5.  C. Clinical features : Most patients are asymptomatic.
Occasionally, diverticulosis is associated with lower abdominal
colicky pain.
 D. Diagnosis of diverticular disease
 l . A history of chronic intermittent lower abdominal pain and
presence of diverticula on barium enema or colonoscopy are
indicative of this condition.
 2. In acute diverticulitis , CT may help distinguish a phlegmon
from an abscess.
 3 . Sigmoidoscopy and colonoscopy should be avoided in acute
flare-ups of the disease because the risk of perforation is high.
DIVERTICULOSIS

6. DIVERTICULOSIS

7. DIVERTICULOSIS
Saw tooth appearance

8.  E. Management
 l . In acute diverticulitis/phlegmon, intravenous (IV) fluids,
antibiotics, and bowel rest are necessary.
 2. Abscesses should be drained, usually percutaneously under CT
guidance.
 3. Fecal peritonitis necessitates exploratory laparotomy. The most
commonly performed operation is the Hartmann procedure, in
which the sigmoid colon is resected, the proximal colon is
exteriorized as a stoma, and the rectal stump is oversewn.
DIVERTICULOSIS

9.  E. Management
 4. Patients who develop strictures may need an elective sigmoid
colectomy and primary anastomosis .
 5 . Fistulae are a complex problem. The patient's nutrition should
be optimized, and infection should be controlled before surgical
repair or resection is attempted
DIVERTICULOSIS

10.  F. Complications
 l . Acute diverticulitis : A diverticulum may become inflamed when
a fecalith obstructs its neck. Patients present with left lower
quadrant abdominal pain, fever, and leukocytosis.
 2. Diverticular abscess: Acute diverticulitis may result in a
peridiverticular abscess. Patients experience severe pain, high
fever, and white bloodcell (WBC) elevation . A CT scan can identify
the collection and guide percutaneous drainage.
 3 . Diverticular phlegmon: The local response to the diverticular
inflammation may lead to formation of an inflammatory mass or
phlegmon. Such patients need bowel rest and IV antibiotics .
DIVERTICULOSIS

11.  F. Complications
 4.Diverticular stricture: Recurrent episodes of inflammation may
lead to fibrosis ,resulting in luminal narrowing. Patients may
present with acute large bowel obstruction.
 5.Fecal peritonitis:Perforation of diverticula may lead to fecal
peritonitis ,which has a mortality rate of about 50% . Patients
need emergency exploratory laparotomy
 6. Hemorrhage: Erosion of a peridiverticular vessel can lead to
significant bleeding.
 7. Fistula: Peridiverticular abscess may erode into adjacent
viscera, forming a fistula
DIVERTICULOSIS

12. Hinchey Classification of Complicated Diverticulitis
• Hinchey 1-pericolic or mesenteric abscess
• Hinchey 2-contained pelvic abscess
• Hinchey 3-generalized purulent peritonitis
• Hinchey 4-generalized feculent peritonitis
DIVERTICULOSIS

13.  A . General principles
 l . In volvulus, the bowel twists on its own mesenteric axis ,
leading to bowel obstruction.
 2 . Venous congestion may lead to bowel infarction
VOLVULUS

14. B. Sigmoid volvulus
 l . Epidemiology and etiology
 a. Sigmoid volvulus accounts for about 5% of all cases of large
bowel obstruction in developed countries. The incidence is higher in
the Third World, which has been attributed to fiber-rich diets.
 b. The narrow mesenteric base of the sigmoid colon, along with an
elongated floppy loop, makes it particularly susceptible to twisting
on its axis .
 c. This condition is seen mostly in elderly, institutionalized patients
with chronic medical and neuropsychiatric conditions .
 d. It is postulated that psychotropic drugs affect colonic motility,
thus predisposing to volvulus .
VOLVULUS

15. VOLVULUS

16. B. Sigmoid volvulus
 2. Clinical features
 a. Patients present with colicky abdominal pain, constipation,
nausea, vomiting, and an inability to pass flatus.
 b . The air is able to enter the sigmoid loop but unable to exit. This
leads to progressive distention of the sigmoid loop.
 c. The abdomen is usually markedly distended and tympanic on
percussion. Severe pain with peritoneal signs is an indicator of
underlying bowel ischemia and/or impending perforation
VOLVULUS

17.  3. Diagnosis
 a. In most patients , the diagnosis can be made on the combination
of history, physical examination, and plain abdominal radiography.
 b. The rectal vault is usually empty on examination.
 c. Plain radiographs show a markedly distended sigmoid loop,
which assumes a bent inner tube or inverted U-shaped appearance,
with the limbs of the sigmoid loop directed toward the pelvis
 d. Single-contrast barium enema examination is useful because it
demonstrates that the barium readily enters the empty rectum and
usually encounters a stenosis, likened to a beak, the so-called bird
beak or bird-of-prey sign.
VOLVULUS

18. VOLVULUS
Coffee bean
appearance
Bird’s beak
appearance

19.  4. Management
 a. Patients may be dehydrated and should be fluid resuscitated.
 b. Early decompression via rigid proctoscopy, flexible
sigmoidoscopy,or colonoscopy should be attempted. This will allow
the mucosa to be visualized for signs of ischemia. The instrument
may pass into the obstructed segment. If this maneuver succeeds,
there is a sudden, dramatic gush of fluid and feces. It is
recommended that a well-lubricated rectal tube be used to prevent
early relapse and facilitate continued drainage.
 c. A full colonoscopy should be performed after bowel preparation to
rule out an associated neoplasm.
VOLVULUS

20.  4. Management
 d . Volvulus can recur in up to 50% of patients ; therefore, elective
sigmoid resection should be offered to all good-risk surgical patients .
 e. Occasionally, it is not possible to decompress the bowel
endoscopically.Alternatively, proctoscopy may reveal mucosal
ischemia suggesting sigmoid necrosis . Such a patient should be
emergently taken to the operating room.
VOLVULUS

21.  A . Epidemiology and etiology
 l . Procidentia is an uncommon condition in which the full thickness
of the rectal wall turns inside out into or through the anal canal. The
extruded rectum is seen as concentric rings of mucosa . The cause is
poorly understood, and the disorder is a form of intussusception. Most
patients have a history of straining with intractable constipation or
chronic diarrhea. There is a high incidence in patients with mental
retardation. Patients have impaired resting and voluntary sphincter
activity and impaired continence.
 2 . Predominates in females with a female:male ratio of 5 : 1 to 6 : 1
RECTAL PROLAPSE

22. RECTAL PROLAPSE

23.  A . Epidemiology and etiology
 3 . Classification
 a. Partial: prolapse of rectal mucosa only
 b. Complete : First degree with an occult prolapse : Several anatomic
defects are constantly demonstrated in patients with chronic rectal
prolapse.
 c. Complete : second-degree ; prolapse to , but not through, the anus
 d. Complete : third-degree; protrusion through the anus for a variable
distance
RECTAL PROLAPSE

24. RECTAL PROLAPSE

25.  B. Clinical features:
 Early symptoms include anorectal discomfort during defecation.
 Feeling of incomplete evacuation is common. In overt prolapse ,
protrusion occurs only during or after defecation. As the problem
becomes more pronounced, the prolapse may be precipitated by
coughing, walking, and exertion. Bleeding from ulcerated mucosa.
 C . Diagnosis:
 Demonstrated on clinical exam by asking the patient to strain or in
the bathroom asking the patient to defecate. Occult prolapse by
defecography.
RECTAL PROLAPSE

26.  D . Management:
 l . The goal is to repair the prolapse and prevent intussusception from
recurring.
 2. The most reliable repair is via the abdomen involving anterior
resection with rectopexy.- Ripstein’s operation
 3. For elderly or unfit patients , a transperineal rectosigmoidectomy is
more appropriate .
 4. Incontinence is due to mechanical stretch of the sphincter as well
as pudendal nerve dysfunction. 50% of patients improve after repair.
RECTAL PROLAPSE

27. RECTAL PROLAPSE

28. RECTAL PROLAPSE

29. THANK YOU