Diverticular Disease and Hemorrhoids Lance T. Uradomo, MD, MPH Assistant Professor of Medicine Division of Gastroenterology and Hepatology University of Maryland School of Medicine Director of Endoscopy, Baltimore VA Medical Center Center for Cancer Surveillance and Control Teleconference Maryland Department of Health & Mental Hygiene January 21, 2009

Outline Diverticular Disease Hemorrhoids Diverticulosis Diverticulitis Diverticular Hemorrhage Hemorrhoids Classification Therapy

Anatomy Transverse Splenic Flexure Hepatic Flexure Descending Sigmoid Ascending Cecum Rectum Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm

Definitions Diverticula – an abnormal pouch or sac opening from a hollow organ (as the colon or bladder) Diverticulosis - the presence of diverticula in the colon Diverticulitis - inflammation or infection of a diverticulum of the colon Diverticular Disease - a disorder characterized by diverticulosis or diverticulitis 2005 Merriam-Webster, Incorporated

Introduction Diverticula form at weak points in the bowel wall Often where vasa recta vessels penetrate the muscle layer Most common in left colon (70-90%) Asia more common in right Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm

Epidemiology Prevalence of Diverticula Age Gender Geography < 10% in people under 40 year old 50% to 66% over age 80 Gender Geography Western countries Low prevalence in Asia and Africa Varies by study due to asymptomatic nature Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125

Pathophysiology 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;357:2057-66

Symptoms of Diverticulosis Most are asymptomatic Some experience crampy pain or discomfort in the lower abdomen, bloating, and constipation.

Acute Diverticulitis Most common complication of diverticular disease 10-25% of patients Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125

Pathophysiology of Diverticulitis Fecalith Bacterial flora Micro or macro perforation Not much known Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm

Presentation of Acute Diverticulitis Symptoms Left lower quadrant pain Fever Leukocytosis Exam Abdominal tenderness Mass High pitched bowel sounds Rebound

Diagnostic Tests Xray – Free air, perforation CT scan Diverticulum Thickening Abscess, fistula Jacobs DO, N Engl J Med 2007;357:2057-66

Diagnostic Tests Colonoscopy 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;357:2057-66

Treatment of Uncomplicated Acute Diverticulitis Antibiotics Jacobs DO, N Engl J Med 2007;357:2057-66

Treatment of Uncomplicated Acute Diverticulitis Hospitalization Inability to tolerate oral medications and liquids Comorbidities Pain severe enough to require narcotic analgesia Symptoms fail to improve despite adequate outpatient therapy Complicated diverticulitis

Complicated Diverticulitis Abscess Peritonitis Obstruction Fistula formation Hemorrhage

Treatment of Complicated Diverticulitis IV antibiotics Bowel rest Analgesia Percutaneous drainage (CT-guided) Surgery

Recurrent Diverticulitis 25% will have more than one attack of acute diverticulitis Parks et al 1969 Recurrence 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 basis American Society of Colon and Rectal Surgeons Sheth et al Am J Gastroenterol 2008; 103: 1550

Diverticular Hemorrhage Rupture of the vasa recta at the dome of a diverticulum Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm

Diverticular Hemorrhage Source proximal to the splenic flexure in 60% Mean age 66 year old Most common cause of life threatening lower GI bleed (3-5% of those with diverticulosis)

Diverticular Hemorrhage Diagnosis History and Physical Exam Painless, sometimes mild cramps Hematochezia (red blood per rectum) Radionucleotide Imaging Technetium sulfur colloid. Scans are obtained shortly after intravenous injection, looking for evidence of extravasation. 0.1 mL/min Sensitivity 97%, specificity 83%, and positive predictive value 94%

Diverticular Hemorrhage Diagnosis Colonoscopy Polyethylene glycol for colon purge preparation Sedation May be therapeutic http://www.uptodate.com/online/content/images/gast_pix/Bleeding_diverticulum_Endos.jpg

Diverticular Hemorrhage Diagnosis Angiography Performed by Interventional Radiologist Bleeding at a rate on 0.5 – 1mL / min May be therapeutic

Therapy for Diverticular Hemorrhage Spontaneous resolution in 90% Colonoscopy: Study found 0% versus 53% rebleeding in colonoscopy vs. medical treatment Epinepherine Cautery Clips Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82 Browder W. Ann Surg 1986 Nov;204(5):530-6

Therapy for Diverticular Hemorrhage Angiography No purge required Vasopressin infusion 91% stop bleeding, but 50% rebleed on cessation of vasopressin Transcatheter 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):78-82 Browder W. Ann Surg 1986 Nov;204(5):530-6

Surgery for Diverticular Hemorrhage Frequency of surgery among patients with severe or massive rectal bleeding from 24 to 78%. 18 – 25% of those requiring transfusions Persistent instability despite aggressive resuscitation demands operative intervention and is necessary Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

Surgery for Diverticular Hemorrhage Surgical mortality is approximately 10% Exploratory laparotomy identifies a source in 78 percent of patients without a preoperative diagnosis Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

Surgery for Diverticular Hemorrhage Segmental colectomy Source of bleeding has been localized Rebleeding in 0 to 14% Subtotal colectomy Patient continues to bleed without an identified site of bleeding Morbidity 37% Mortality rates 11 – 33% Blind segmental resection is contraindicated Rebleeding rate 42% Morbidity 83% Mortality 57 % Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com

Recurrence of Diverticular Hemorrhage 1 year 9% 2 year 10% 3 year 19% 4 year 25% Longstreth. Am J Gastroenterol 1997; 92: 419

Hemorrhoids Bleday R. Treatment of hemorrhoids. Uptodate.com

Hemorrhoids Arise from a plexus of dilated veins arising from the superior and inferior hemorrhoidal veins. Submucosal layer in the lower rectum External or internal: below or above the dentate line.

Classification Grade 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.

Bleeding 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 patients Colonoscopy Pain should prompt looking for another source

Pruritus Irritation or itching of perianal skin Some patients also complain of mild incontinence or wetness.

Pain Thrombosis, 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

Therapy: American Society of Colon and Rectal Surgeons (ASCRS) Guidelines Conservative (not generally effective in Grades III, IV) Fiber Meta-analysis of seven controlled trials found a significant and consistent benefit from fiber supplementation in improving bleeding (RR 0.50, 95% CI 0.28-0.68) Also potentially useful: Sitz baths help to relieve irritation and pruritus. In warm water two to three times per day. Topicals Steroids Alonso-Coello P, et al. Cochrane Database Syst Rev 2005;(4):CD004649.

Therapy Minimally invasive Mostly for Internal Grades I, II, III. Band ligation Coagulation Sclerotherapy Cryotherapy

Therapy 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

Therapy 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.

Summary Diverticular Disease Diverticulosis is common and usually asymptomatic. Symptoms range from mild cramping and bowel movement changes to life threatening infection or hemorrhage Diverticulitis is an infection of an diverticulum Uncomplicated cases can be treatment with outpatient oral antibiotics Severe or complicated cases may require hospitalization and invasive therapeutic modalities

Summary Diverticular Bleeding Is a common cause of massive lower GI hemorrhage Colonoscopy and angiography may be diagnostic and therapeutic Surgery is reserved for uncontrolled or refractory cases with best outcomes when the site of bleeding has been localized

Summary Hemorrhoids 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

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