Diverticular disease Presented by:farahnaz.kardan

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 )

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

. Barium enema with extensive sigmoid diverticulosis

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

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

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…

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

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

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

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

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

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

Investigations - CT Air-filled diverticula Mesenteric stranding

Investigations - CT Air in bladder Thickened wall

THE END