1. H.K. Oh M.D. Department of General Surgery
Diverticular Disease
H.K. Oh M.D.
Department of General Surgery

3. Overview
A diverticulum is an abnormal sac or pouch protruding from the wall of a hollow organ.
Diverticula ; pouches
Diverticulosis ; condition of having diverticula
Diverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution.
Decreased consumption of unprocessed cereals along with the increased consumption of sugar and meat
The formation of diverticula is also related to aging
Rare in individuals younger than the age of 30 years, but at least two thirds of Americans will have developed colonic diverticula by the age of 80.

4. Pathogenesis
Diverticula are actually herniations of mucosa through the colon at sites of penetration of the muscular wall by arterioles
On the mesenteric side of the antimesenteric teniae
Sigmoid colon
The most common site (50%)
The smallest luminal diameter.
Low fiber diet -> decreased colonic luminal content -> high intraluminal pressures to propel the feces forward -> herniations of mucosa through the anastomically weak points in the colonic wall

5. Diverticular bleeding
The most common cause of hematochezia in patients over the age of 60
20% of patients with diverticulosis will have GI bleeding.
Risk factor ; HT, Artherosclerosis, NSAID
Usually self limited, but rebleeding risk (25%)
Localization ; Colonoscopy, Angiography
Surgery
Unstable hemodynamics, 6-unit bleed within 24 hr
Without localization ; Total colectomy

6. Diverticulitis Definition Presentation
Inflammation of a diverticulum, is related to the retention of particulate material within the diverticular sac and the formation of a fecalith
Actually an extraluminal pericolic infection caused by the extravasation of feces through the perforated diverticulum
Presentation
LLQ pain : may radiate to the suprapubic, groin, back
Bowel habit change, Anorexia, Fever, Chill, Urinary urgency

7. Diverticulitis Physical Findings
Dependent on the site of perforation, the amount of contamination, and the presence or absence of secondary infection of adjacent organs
Tenderness, Muscle guarding
Tender mass : phlegmon or abscess
Abdominal distension : ileus or obstruction
Tender fluctuant pelvic mass on rectal or vaginal exam

8. Diverticulitis Diagnostic Tests CT MRI, US
The preferred test to confirm the suspected diagnosis
Location of infection, extent of inflammatory process, presence and location of an abscess, secondary complications
sigmoid diverticula, thickened colonic wall >4 mm, inflammation within the pericolic fat ± the collection of contrast material or fluid
MRI, US
Water soluble contrast enema
Distinguish acute diverticulitis from perforated cancer
Risk of increasing the colonic pressure, extravasation of feces through the perforated diverticulitis

9. Uncomplicated Diverticulitis
Disease not associated with free intraperitoneal perforation, fistula formation, or obstruction
Nonoperative treatment
Bowel rest + Antibiotics ; 75% response
Trimethoprim/sulfamethoxazole or ciprofloxacin and metronidazole ; aerobic gram-negative rods and anaerobic bacteria
The addition of ampicillin to this regimen for nonresponders ; enterococci
Single-agent therapy ; a third-generation penicillin such as piperacillin
The usual course of antibiotics is 7 to 10 days

10. Uncomplicated Diverticulitis
Investigative studies
After the symptoms have subsided for at least 3 weeks
To establish the presence of diverticula and to exclude cancer, which can mimic diverticulitis
Colonoscopy > Barium enema
Recurrent disease
Second attack (<25%) -> Third attack (>50%)
Elective resection
After infection control ; usually 4 to 6 weeks after the episode
Laparoscopic resection ; growing trend
Immunocompromised patient : after single attack

11. Complicated Diverticulitis
Hinchey classification
Stage I: Pericolic or mesenteric abscess
Stage II: Walled-off pelvic abscess
Stage III: Generalized purulent peritonitis
Stage IV: Generalized fecal peritonitis

12. Complicated Diverticulitis Abscess
Usually confined to the pelvis
Significant pain, fever, and leukocytosis
More than 2cm ; should be drained
Percutaneous or transanal > laparotomy
Elective surgery ; after 6weeks following drainage
Complete removal of the entire abnormally thickened bowel

13. Complicated Diverticulitis Fistula
Skin, bladder, vagina, or small bowel
Sigmoid-vesical fistula
Pneumaturia, fecaluria, and recurrent UTI (Urosepsis)
CT ; may demonstrate air in the bladder
Barium enema, IVP, Cystoscopy
Treatment
Initial treatment ; infection control and reduce the associated inflammation
Rarely a cause for emergency surgery
Diagnostic steps such as coloscopy should be taken to confirm the cause of the fistula before a definitive operation is undertaken.

14. Generalized Peritonitis
Mechanism
Perforation without sealing by the body’s normal defenses -> contaminated with feces
Abscess burst into the unprotected peritoneal cavity -> contaminated with enteric bacteria
Immediate operative intervention
Excise the segment of colon containing perforation and construct a colostomy using noninflammed colon
Peritoneal cavity irrigation, iv antibiotics
Colostomy repair
Usually after a period of at least 10 weeks

15. Diverticulosis in Korea
Characteristics
Low incidence, but increasing
Rt colon (over 60%) > Lt colon
Young Age, Man, Congenital, Solitary, True type, Uncomplicated type
Differential Diagnosis from Acute Appendicitis
RLQ pain ; first symptom site, long duration
Nausea, vomiting ; absent or low
Previous appendectomy
Known diverticulosis (Barium enema, Colonoscopy)
Fecalith
Age ; 30~40 year old (later than appendicitis)
History of lower GI bleeding

16. References Sabiston Textbook of Surgery 17ed
Harrison’s Principles of Internal Medicine 16th
Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current management of diverticulitis. Curr Surg Jul-Aug;61(4):361-5
Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg Dec;199(6):
Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid colectomy after acute diverticulitis: when to operate? Surgery Oct;136(4):
Park JK et al. Clinical analysis of right colon diverticulitis. J Korean Surg Soc 2003 Jan;64:44-48
Chang JH et al. Surgical treatment of the colonic diverticulosis. J Korean Surg Soc 2002 May;62:

17. Thank you for your attentions.