1. Diverticular disease Presented by:farahnaz.kardan

2. Definitions Colonicdiverticulum: herniation of mucosa and muscularis mucosa through colonic wall (technically, a false diverticulum) Diverticulardisease: presence of symptomatic diverticula Diverticulitis: inflammation and infection associated with diverticula )

3. Epidemiology very common in Western world ~50% people > 50 y.o.

4. . Barium enema with extensive sigmoid diverticulosis

5. Etiology  fibre diet  stool volume  intraluminal pressure  colonic wall tension muscular hypertrophy, pulsion diverticula  tensile strength  elasticity  age

6. Uncomplicated Diverticulitis Infection, inflammation of diverticulum Presentation: LLQ pain, tenderness CT:  pericolic soft-tissue stranding  colonic wall thickening  phlegmon

7. Uncomplicated Diverticulitis: treatment Acute Bowel rest iv antibiotics Merperidine better than morphine 3 weeks later Scope to rule out cancer 4-6 weeks later Elective resection, if appropriate…

8. Indications operationfor elective ≥ 2 acute attacks, successfully treated medically one attack requiring hospitalization in patient < 40 y.o. one complicated attack one attack in immunocompromised patient inability to rule out colonic carcinoma

9. Complicated Diverticulitis Abscess Obstruction Diffuse peritonitis (free perforation) Fistulas, e.g., colovesical, colovaginal, coloenteric, colocutaneous

10. Complicated Diverticulitis, Abscess Hinchey Stage Ipericolic abscess IIretroperitoneal or pelvic abscess IIIpurulent peritonitis IVfecal peritonitis

11. Complicated Diverticulitis, Abscess Hinchey Stages I (pericolic abscess) and II (retroperitoneal or pelvic abscess) Pre-op CT-guided percutaneous drainage Elective resection, primary re-anastomosis Hinchey Stage III (purulent peritonitis) Emergent Hartmann’s procedure, or Emergent resection, primary re-anastomosis Hinchey Stage IV (feculent peritonitis) Emergent Hartmann’s procedure

12. Complicated Diverticulitis, Fistula Treat acute attack Elective resection, primary re-anastomosis

13. Investigations Townsend: Sabiston Textbook of Surgery, 17th ed., 2004

14. Investigations - CT Air-filled diverticula Mesenteric stranding

15. Investigations - CT Air in bladder Thickened wall

16. THE END