Presentation on theme: "Diverticular Disease and Hemorrhoids"— Presentation transcript:
1Diverticular Disease and Hemorrhoids Lance T. Uradomo, MD, MPHAssistant Professor of MedicineDivision of Gastroenterology and HepatologyUniversity of Maryland School of MedicineDirector of Endoscopy, Baltimore VA Medical CenterCenter for Cancer Surveillance and Control TeleconferenceMaryland Department of Health & Mental HygieneJanuary 21, 2009
3Anatomy Transverse Splenic Flexure Hepatic Flexure Descending Sigmoid AscendingCecumRectumStone C.
4DefinitionsDiverticula – an abnormal pouch or sac opening from a hollow organ (as the colon or bladder)Diverticulosis - the presence of diverticula in the colonDiverticulitis - inflammation or infection of a diverticulum of the colonDiverticular Disease - a disorder characterized by diverticulosis or diverticulitis2005 Merriam-Webster, Incorporated
5Introduction Diverticula form at weak points in the bowel wall Often where vasa recta vessels penetrate the muscle layerMost common in left colon (70-90%)Asia more common in rightStone C.
6Epidemiology Prevalence of Diverticula Age Gender Geography < 10% in people under 40 year old50% to 66% over age 80GenderGeographyWestern countriesLow prevalence in Asia and AfricaVaries by study due to asymptomatic natureMartel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125
7Pathophysiology of Diverticula Associations with diets low in dietary fiber and high in refined carbohydrates.Less bulky stools that retain less water and may alter gastrointestinal transit time;Increase intracolonic pressure and make evacuation of the colonic contents more difficult.Other factors:physical inactivity, constipation, obesity, smoking, and treatment with nonsteroidal antiinflammatory drugs.Jacobs DO, N Engl J Med 2007;357:
8Symptoms of Diverticulosis Most are asymptomaticSome experience crampy pain or discomfort in the lower abdomen, bloating, and constipation.
9Acute Diverticulitis Most common complication of diverticular disease 10-25% of patientsMartel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125
10Pathophysiology of Diverticulitis FecalithBacterial floraMicro or macro perforationNot much knownStone C.
12Diagnostic Tests Xray – Free air, perforation CT scan Diverticulum ThickeningAbscess, fistulaJacobs DO, N Engl J Med 2007;357:
13Diagnostic TestsColonoscopy and sigmoidoscopy are typically avoided when acute diverticulitis is suspected because of the risk of perforation.Recommended after approximately 6 weeks, to rule out the presence of other diseases, such as cancer and inflammatory bowel disease.Jacobs DO, N Engl J Med 2007;357:
14Treatment of Uncomplicated Acute Diverticulitis AntibioticsJacobs DO, N Engl J Med 2007;357:
15Treatment of Uncomplicated Acute Diverticulitis HospitalizationInability to tolerate oral medications and liquidsComorbiditiesPain severe enough to require narcotic analgesiaSymptoms fail to improve despite adequate outpatient therapyComplicated diverticulitis
17Treatment of Complicated Diverticulitis IV antibioticsBowel restAnalgesiaPercutaneous drainage (CT-guided)Surgery
18Recurrent Diverticulitis 25% will have more than one attack of acute diverticulitisParks et al 1969Recurrence was more virulent and lead to recommendation for elective resection after the second episode in >50year old and after first episode in younger patients.More recent data fails to show worse prognosis in recurrent attacks.American Society of Colon and Rectal Surgeons:Decision for elective resection is on a case by case basisAmerican Society of Colon and Rectal SurgeonsSheth et al Am J Gastroenterol 2008; 103: 1550
19Diverticular Hemorrhage Rupture of the vasa recta at the dome of a diverticulumStone C.
20Diverticular Hemorrhage Source proximal to the splenic flexure in 60%Mean age 66 year oldMost common cause of life threatening lower GI bleed (3-5% of those with diverticulosis)
21Diverticular Hemorrhage Diagnosis History and Physical ExamPainless, sometimes mild crampsHematochezia (red blood per rectum)Radionucleotide ImagingTechnetium sulfur colloid. Scans are obtained shortly after intravenous injection, looking for evidence of extravasation. 0.1 mL/minSensitivity 97%, specificity 83%, and positive predictive value 94%
22Diverticular Hemorrhage Diagnosis ColonoscopyPolyethylene glycol for colon purge preparationSedationMay be therapeutic
23Diverticular Hemorrhage Diagnosis AngiographyPerformed by Interventional RadiologistBleeding at a rate on 0.5 – 1mL / minMay be therapeutic
24Therapy for Diverticular Hemorrhage Spontaneous resolution in 90%Colonoscopy: Study found 0% versus 53% rebleeding in colonoscopy vs. medical treatmentEpinepherineCauteryClipsJensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82Browder W. Ann Surg 1986 Nov;204(5):530-6
25Therapy for Diverticular Hemorrhage AngiographyNo purge requiredVasopressin infusion91% stop bleeding, but 50% rebleed on cessation of vasopressinTranscatheter embolization is more definitive, but is associated with a up to 20% risk of intestinal infarction.Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82Browder W. Ann Surg 1986 Nov;204(5):530-6
26Surgery for Diverticular Hemorrhage Frequency of surgery among patients with severe or massive rectal bleeding from 24 to 78%.18 – 25% of those requiring transfusionsPersistent instability despite aggressive resuscitation demands operative intervention and is necessarySummarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
27Surgery for Diverticular Hemorrhage Surgical mortality is approximately 10%Exploratory laparotomy identifies a source in 78 percent of patients without a preoperative diagnosisSummarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
28Surgery for Diverticular Hemorrhage Segmental colectomySource of bleeding has been localizedRebleeding in 0 to 14%Subtotal colectomyPatient continues to bleed without an identified site of bleedingMorbidity 37%Mortality rates 11 – 33%Blind segmental resection is contraindicatedRebleeding rate 42%Morbidity 83%Mortality 57 %Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
29Recurrence of Diverticular Hemorrhage 1 year 9%2 year 10%3 year 19%4 year 25%Longstreth. Am J Gastroenterol 1997; 92: 419
30HemorrhoidsBleday R. Treatment of hemorrhoids. Uptodate.com
31HemorrhoidsArise from a plexus of dilated veins arising from the superior and inferior hemorrhoidal veins.Submucosal layer in the lower rectumExternal or internal: below or above the dentate line.
32ClassificationGrade I: May bulge into the lumen but do not extend below the dentate line.Grade II: Prolapse out of the anal canal with defecation or with straining but reduce spontaneously.Grade III: Prolapse out of the anal canal with defecation or straining, and require the patient to reduce them into their normal position.Grade IV: Irreducible and may strangulate.
33Bleeding Painless bleeding usually associated with a bowel movement. Bright red blood coats the stool at the end of defecation.Blood may drip into the toilet or stain toilet paper.Chronic blood losses from hemorrhages can be substantial enough to induce iron deficiency anemia.Bleeding should be investigated:Flexible sigmoidoscopy or anoscopy in low-risk younger patientsColonoscopyPain should prompt looking for another source
34Pruritus Irritation or itching of perianal skin Some patients also complain of mild incontinence or wetness.
35PainThrombosis, which can occur in both internal and external hemorrhoids. Thrombosis of external hemorrhoids may be associated with excruciating pain.Easily visible, purple, elliptical mass extending from the anal to the perianal skin.Thrombosed internal hemorrhoids may also cause pain, but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids strangulate
36Therapy: American Society of Colon and Rectal Surgeons (ASCRS) Guidelines Conservative (not generally effective in Grades III, IV)FiberMeta-analysis of seven controlled trials found a significant and consistent benefit from fiber supplementation in improving bleeding (RR 0.50, 95% CI )Also potentially useful:Sitz bathshelp to relieve irritation and pruritus. In warm water two to three times per day.TopicalsSteroidsAlonso-Coello P, et al. Cochrane Database Syst Rev 2005;(4):CD
37Therapy Minimally invasive Mostly for Internal Grades I, II, III. Band ligationCoagulationSclerotherapyCryotherapy
38Therapy Surgery For refractory to above Thrombosed external Complications following a standard closed hemorrhoidectomy include urinary retention, urinary tract infection, fecal impaction, delayed hemorrhage, and pain
39Therapy In patients with thrombosed external hemorrhoids Either observation or excision. Excision within 48 to 72 hours of the onset of symptoms will result in the most rapid relief of symptoms.
40Summary Diverticular Disease Diverticulosis is common and usually asymptomatic.Symptoms range from mild cramping and bowel movement changes to life threatening infection or hemorrhageDiverticulitis is an infection of an diverticulumUncomplicated cases can be treatment with outpatient oral antibioticsSevere or complicated cases may require hospitalization and invasive therapeutic modalities
41Summary Diverticular Bleeding Is a common cause of massive lower GI hemorrhageColonoscopy and angiography may be diagnostic and therapeuticSurgery is reserved for uncontrolled or refractory cases with best outcomes when the site of bleeding has been localized
42SummaryHemorrhoids are common and can cause bleeding, itching, or pain (with thrombosis)Mild cases can be treated with fiber supplements and topical medications.Minimally invasive (endoscopic) techniques are available.Surgery is reserved for severe cases or thrombosis