1. Diverticulitis-an update
Dr Bernard Stacey
Consultant Gastroenterologist
SUHT

2. Aims The natural history of diverticular disease
Medical treatment for the majority of patients with diverticular disease?
Who needs surgery?
Is age a problem?
What about patients with chronic LIF pain and associated diverticular disease?

3. Diverticulae
Colonic diverticula are mucosal outpouchings through the large bowel wall
Often accompanied by structural changes (elastosis of the taenia coli, muscular thickening, and mucosal folding)
Usually multiple
Most frequently in the sigmoid colon

4. Geography/Diet Diverticulosis is common in resource-rich countries
There is a lower prevalence of diverticulosis in Western vegetarians consuming a diet high in fibre
Diverticulosis is almost unknown in rural Africa and Asia

5. Spectrum of presentation
Majority of people with colonic diverticula are asymptomatic
= Diverticulosis
20% develop symptoms at some point
= Diverticular disease
When diverticulum becomes acutely inflamed
=Acute diverticulitis

6. Complex Colonic Diverticular Disease
Jacobs D. N Engl J Med 2007;357:

7. Complications Complications of diverticular disease
perforation
obstruction
haemorrhage
fistula formation
are each seen in about 5% of people with colonic diverticula when followed up for 10–30 years
UK incidence of perforation is 4 cases/100,000 people a year, leading to approximately 2000 cases annually

8. Prevalence of Diverticulosis
5% to 10% before age 50
30% after age of 50
50% over age70
66% over age 85
Natural history of diverticular disease of the colon Parks TG

9. Hinchey Classification Scheme
Hinchey 1 - peri-diverticular abscess within the mesocolon
Hinchey II - distant (pelvic, retroperitoneal) abscess
Hinchey III - generalized purulent peritonitis
Hinchey IV – generalised faecal peritonitis
Figure 2. Hinchey Classification Scheme. Patients with stage 1 disease have small, confined pericolic or mesenteric abscesses, whereas those with stage 2 disease have larger abscesses, often confined to the pelvis. Stage 3 disease, or perforated diverticulitis, is present when a peridiverticular abscess has ruptured and caused purulent peritonitis. Rupture of an uninflamed and unobstructed diverticulum into the free peritoneal cavity with fecal contamination, the so-called free rupture, signifies stage 4 disease and carries the highest risk of an adverse outcome.
Jacobs D. N Engl J Med 2007;357:

10. How to treat? If can tolerate fluids and have no peritonitis
Fluids or Low residue liquid diet
Pain relief
Antibiotics (7-10 days) of oral broad spectrum antimicrobial therapy – ciprofloxacin and metronidazole
Need imaging of bowel to exclude other pathology (10%)
Management can be repeated
Consider hospital if unable to tolerate fluids, cannot manage pain, fails to improve or has complicated diverticulitis

11. Acute hospital admission
Drip (+/- suck)
IV antibiotics CT
high sensitivity – 93-97%
specificity – 100%
Barium enema / colonoscopy / flex sig to check for other pathology (avoid for 6 weeks)

12. CT Scans of the Colon in Four Patients with Diverticulitis of Varying Severity

13. Who needs operation? Hinchey I - conservative
Hinchey II distal or large abscess > 4cm: CT drainage
Less than 10% of Hinchey I and II need operation
Hinchey III – usually operation
Hinchey IV – always operation

14. Outcome at presentation– Hinchey stage
Risk of death:
<5% for most patients with stage 1 or 2
13 % for stage 3
43% for stage 4

15. Does one or more attacks predict further or more serious ones?NO
>50% of patients presenting to hospital with complicated diverticular disease - first presentation
70% of these will have perforation

16. What happens after first attack?
Recurrent diverticulitis is observed in 7–42%
2551 patients followed up over 9 years – 13% recurrent attacks and 7% required surgery
10% recurrence in 1st year and 3% each year afterwards

17. Medical treatment Fibre Probiotics 5ASA Lancet 1977 Broadribb
18 patients single randomised controlled trial with crossover. Stopped at 3 months
Caused a reduction in symptoms!
Probiotics
2 small trials
Longer remission
5ASA
3 trials
Reduce peridiverticular inflammation

18. Patients over 75 years old
Age <75
Age >= 75
No of colectomies
9458
2532
In hospital death 4%
13%
1 year mortality
18%
Discharged home
61%
27%
Median stay
10 days
13 days
data from California
Parikh and Ko ASCRS 2008

19. Disease progression
Inflammation will develop in 10–25% of people with diverticula at some point
Even after successful medical treatment of acute diverticulitis, almost two thirds of people suffer recurrent pain in the lower abdomen

20. Spectrum of symptoms with IBS
People with uncomplicated diverticular disease may report
abdominal pain (principally colicky left iliac fossa pain)
bloating
altered bowel habit
may have mild left iliac fossa tenderness on examination.

21. To operate or not?
Decreasing morbidity and mortality with laparoscopic colonic surgery
Some cases of chronic pain and recurrent attacks do extremely well
Need to ‘earn’ their surgery and understand the risks

22. Summary Most people in the Western World will develop diverticulae
Most will remain asymptomatic
The most serious complication is faecal perforation (43% mortality) – most likely to occur at first attack
After first attack of complicated diverticulitis 10% recur in the first year – then 3% per year

23. Summary If can tolerate fluids
Treat at home with fluids, antibiotics for 7-10 days and then put on fybogel, probiotics and ?ASA
If cannot manage pain relief or fluids, or patient sick admit
2 attacks no longer means surgery
Tailor on-going management plan according to patient needs

24. Conclusion
Perforated diverticulitis kills but we cannot predict the group in whom this occurs
Surgery kills – must think carefully before doing surgery