1. Portland Gastroenterology Center
Diverticulosis
Andreas Stefan MD
Portland Gastroenterology Center
Maine Medical Center
March 21, 2015

2. Overview Epidemiology Pathophysiology Diverticulitis Bleeding
Segmental Colitis Associated with Diverticulosis (SCAD)
Symptomatic Uncomplicated Diverticular Disease (SUDD)

3. Epidemiology Age – In the United States Male/female incidence the same
1/3 by age 60
2/3 by age 85
Male/female incidence the same
Diet – low fiber, high meat and sugar
Uncommon in Southeast Asia and Africa
Very common in Australia, US, Europe and Canada
Immigration studies (Africans moving to Sweden)
First report of surgery for diverticular disease by Mayo 1907
R sided in Asia – e.g Singapore 75% R side vs 25 sigmoid
Moving data: Africans/Asians to Sweden hospitalization gap went away after 10 years; Japanese moving to Hawaii

5. Why does diverticulosis develop?

6. Pathogenesis of Diverticulosis
Exaggerated segmental contractions
Laplace’s law P = kT/R (sigmoid colon is narrowest portion of colon)
Patients with diverticular disease demonstrate higher pressures in colon than controls
Old theory speculated that local trauma by stool contents that may injure the wall of colon – e.g. seeds, nuts etc . . .
Typical diverticulum is in fact a pseudodiverticulum since not all layers are contained (no muscularis propria)

7. Segmental Contraction

8. Etiology of Diverticulosis
Diverticuli don’t arise randomly around the circumference of the colon; 4 rows between mesenteric side of taenia libra and omentalis and not in anti mesenteric intertaenial area

9. Diverticulitis

10. Colonic Anatomy

11. Risk of Diverticulitis

12. Clinical Presentation
Symptoms
Fever and/or chills 50% time
Left lower quadrant or lower abdominal pain
Change in bowel habits
Urinary symptoms including dysuria or pneumaturia (no hx diverticulitis in many)
Presence of localized or generalized peritonitis (micro/macroperforation)
R sided disease can mimic appendicitis
R sided diverticulitis can mimc appendicitis

13. Diagnosis Labs frequently show elevated WBC
Role of colonoscopy limited
CT scan valuable
Typically looking for 2 of 3 elements to establish diagnosis: symptoms, labs, and or CT
One study with 45% normal WBC

14. Diagnosis Computed Tomography (CT)
CT Scan with contrast – diagnostic test of choice with sensitivity of 94% and specifity 81% in pts with classic symptoms
Reliably shows the segment of bowel and the extent of disease
Identifies abscess and fistula formation
Reveals involvement of adjacent organs such as the small bowel, bladder and abdominal wall
Can be used to guide percutaneous drainage
Can be used to classify severity of diverticulitis

15. CT classification or grading
Modified Hinchey Staging – Originally based on clinical findings at surgery
Stage 0: LLQ pain, elevated WBC, fever, no confirmation by imaging or surgery
Stage Ia: Confined pericolic inflammation or phlegmon
Stage Ib: Confined pericolic abscess
Stage II: Pelvic, distant intraabdominal or retro-peritoneal abscess
Stage III: Generalized purulent peritonitis
Stage IV: Generalized feculent peritonitis

16. Stage 0 Often seen by PCP, GI or ER
Generally treated with oral antibiotics
Cipro/Flagyl, Bactrim
Augmentin, Avelox
Low residue diet initially
High fiber diet once symptoms resolve
Need for interval colonoscopy being questioned

17. Stage Ia

18. Follow up of Stage 0 and Ia
Careful history regarding prior attacks including number, frequency, severity, and comorbidities including immunosuppression
Interval colonoscopy to rule out malignancy
High fiber diet
<25% will have second attack
Risk of third attack >50% after second attack
Resection for patients with multiple attacks

19. Stage Ib or II Percutaneous drainage if possible
Transrectal drainage of pelvic abscess
IV antibiotic
Close clinical observation
Affords possibility of single stage operation

20. Stage Ib or II Complicated Diverticulitis
Close follow up to assure resolution of symptoms and monitor for recurrence
Interval colonoscopy to rule out malignancy
Segmental resection with primary anastomosis 4-6 weeks after episode
Risk of recurrence if managed conservatively secondary to complications of diverticulitis (abscess, stricture or fistula)
MN study 42% pts not undergoing resection developed recurrent problems over 7 years (comorbidities)
2006 American Society of Colon and Rectum Surgeons guideline for resection
Gaertner WB Dis Col Rectum 2013

21. Stage III and IV Complicated Diverticulitis
Can be difficult to distinguish on CT Scan or clinically
Generalized or Localized Peritonitis
Sepsis
Fever
Elevated WBC

22. Stage III and IV Complicated Diverticulitis
Usually require emergent operative intervention
Hartman’s Procedure (1921) Colostomy with closure of distal bowel
Primary anastomosis with diverting loop ileostomy in select cases
Laparoscopic lavage with drainage and interval sigmoid colectomy

23. Stage III and IV Complicated Diverticulitis

24. Stage III or IV Complicated Diverticulitis
Requires a second operation to restore intestinal continuity
High percentage of patients never have them reversed (25- 70%)
Morbidity associated with stomas
Change in body image
Difficulty with stomal pouching
Peristomal hernia
Stomal retraction
Stomal prolapse

25. Indications for Elective Resection
After two episodes one should seriously consider elective resection
Immunosuppression
Ib and above disease
Fistula
Stricture

26. Colonic Fistulas Complicated Diverticulitis
Colo-cutaneous fistula
May be a consequence of percutaneous drainage of pericolic abscess
Colo-vesicular fistula
50% of patients will not remember having diverticulitis
Men > Women
Pneumaturia, fecaluria, frequent UTI’s
Colo-vaginal fistula
Generally seen in post hysterectomy female
Sigmoid adhesions to the pelvis

27. Colonic Fistula Complicated Diverticulitis
Rarely a cause for emergent surgery
Patient often improves with fistula formation
IV antibiotics
Await decrease in inflammation

28. Colonic Stricture Complicated Diverticulitis
Usually due to adhesion formation or as a result of recurrent inflammation and scarring
Often difficult to distinguish from Crohn’s disease or carcinoma on imaging
May be asymptomatic and identified at the time of colonoscopy
Diagnosis may be accomplished with barium enema or CT with retrograde contrast
If diagnostic uncertainty then surgical resection is recommended

29. Colonic Stricture

30. Can we eat Seeds, Nuts and Popcorn?

31. Can we eat Seeds, Nuts and Popcorn?
Recommendation to avoid seeds, nuts and popcorn was a result of the theory from the 1960’s (direct trauma, obstruction) – no data
Current epidemiologic data supports the intraluminal pressure model of diverticulosis
However, the avoidance of seeds, nuts and popcorn persists
Luminal trauma ppt of diverticulitis and bleeding; but nuts are good for you

32. Can we eat Seeds, Nuts and Popcorn?
Health Professionals Follow-up Study
Cohort of US men (51,529) followed prospectively from – 2004
Follow diet, life style and medical history with biennially questionaire
90% mean followup
Primary endpoints diverticulitis and diverticular bleeding
Strate et al, JAMA 2008

33. Can we eat Seeds, Nuts and Popcorn?
801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding
Looked at nut, corn and popcorn consumption and diverticulitis and diverticular bleeding
Found nut, corn and popcorn consumption did not increase the risk of diverticulitis or diverticular complications
Inverse associations between nut and popcorn consumption and the risk of diverticulitis in patient’s who consumed them >2x/week
Strate et al, JAMA 2008

34. Can we eat Seeds, Nuts and Popcorn?
Yes!

35. Diverticular bleeding

36. Bleeding Colonic Diverticulum

37. Clipping of Bleeding Diverticulum

38. Diverticular Bleeding
5-15% with diverticulosis will develop bleeding
Usually painless and not a/w diverticulitis
50% bleeding proximal to splenic flexure
Stops spontaneously majority of time
Risk of second bleed 20%, third bleed 50%
Bursts of larger bleeding (not small frequent)

39. Therapeutic Colonoscopy
Jensen et al NEJM 2000
10 of 48 patients (21%) presenting with diverticular hemorrhage had bleeding site identified
Treated with injection and/or cautery
No rebleeds at median f/u 30 months
Colonoscopy within 12 hours of admit

40. Findings May Not Be Generalizable
High rate of bleeding site identification, other studies 5-15%
Endoscopic treatment riskier given tissue thickness
Bit of an outlier in terms of rebleed (other studies show rates as high as 38%)

41. Segmental Colitis Associated with Diverticulosis (SCAD)

42. Segmental Colitis Associated with Diverticulosis

43. Segmental Colitis Associated with Diverticulosis
May be asymptomatic or have hematochezia and abdominal pain – rectum spared
Average age onset 62
Dx made endoscopically and histologically
Interdiverticular mucosa inflamed without involvement of diverticular orifices (oppose diverticulitis or IBD)
Histologically ranges from modest inflammation to prolapse to chronic inflammation with crypt abscesses and distorted crypt architecture

44. SCAD Natural history incompletely understood
Histologically resembles IBD, infx and ischemic colitis
One study 10% went on to Crohns over 6 year f/u
Treatment with 5 ASA, antibiotics, probiotics, even infliximab
Elevated TNF alpha

45. Terminology

46. Symptomatic Uncomplicated Diverticular Disease (SUDD)
Commonly LLQ pain often worse after eating and better with defecation of passage of flatus
Overlap with IBS and question late consequence
Diverticulosis may not be just an intermittent condition
Surgical resection series at Mayo: 47 pt with 12 month f/u on 68%. Resolution of symptoms 77% and 88% pain free (76% of specs with acute/chronic inflammation)

47. Medical Treatment Options for Recurrent Diverticulitis, SCAD and SUDD
Mesalamine
Rifaximin
Probiotics
Fiber

48. Treatment Mesalamine
Given evidence of chronic inflammation in patients with diverticular disease
Trepsi et el: 400 bid mesalamine x 8 wks after acute attack: 15% vs 46% relapse after 4 years vs placebo
Tursi et al: continuous mesalamine 1.6g/day better than 10d/month: 78 vs 56% symptom free (SUDD)
Systematic review 818 pts with uncomplicated diverticulitis or SUDD found mesalamine better at relief of symptoms
Studies with limitations including lack of adequate control groups and open label design
More recently PREVENT 1 and 2 and DIVA trials performed

49. Treatment Mesalamine (for prevention of recurrent diverticulitis)
PREVENT 1 and 2 trials
584 pts with resolved diverticulitis 1.2, 2.4 or 4.8 g mesalamine daily for 2 years
No difference in recurrent attacks
DIVA trial (MC, PC, DB) mesalamine better symptom response compared with placebo (probiotic no additional benefit) in pts with CT documented diverticulitis but no change in recurrent diverticulitis

50. Treatment Rifaximin
Tursi et al: 218 pts recurrent diverticulitis randomized to rifaximin 400 bid 7 days per month and mesalamine 800 mg bid: combination better than placebo at symptoms relief 86 vs 49% and preventing recurrence 3 vs 18%.
Meta-analysis: 64% vs 35% pts treated with rifaximin and fiber vs fiber alone were symptom free at 1 year follow up. NNT 3 for rifaximin vs placebo to achieve symptom relief

51. Treatment Probiotics Small uncontrolled studies
DIVA (looked at preventing recurrence diverticulitis) study without benefit

52. Fiber Probably protective
0.58 RR in Health Professionals Study (n= 51,000) between highest quintile vs. lowest quintile of fiber intake
> 30g fiber a day likely necessary (apple = 4 g;
Low fiber initially after an attack then high (although no clear evidence this prevents future attacks)
Some patients with stricturing may not tolerate a high fiber diet

53. Conclusions
Common but most don’t go on to complications such as bleeding or diverticulitis
OK to eat seeds/nuts and popcorn
May not just be an acute disease – consider SCAD and SUDD
New treatment regimens may be effective at preventing recurrent attacks and/or reducing symptoms