1. DIVERTICULITIS Bernard M. Jaffe, MD Professor of Surgery, Emeritus

2. DIVERTICULA True- Involves All Layers of Bowel False- Involves a Portion of Bowel Wall Pseudo- Herniation of Mucosa Through Wall- No Muscularis Colonic Diverticula are False or Pseudo- Diverticula

3. DIVERTICULOSIS Presence of Diverticula With No Implication of Number or Location Rare 80 Years Diets Low in Fiber, High in Carbohydrates, Meats

4. DIVERTICULA Occur at Sites of Penetration of Wall by Vessels Mesenteric Side of the Colon Between Mesenteric and Two Lateral Taeniae Colonic Musculature Becomes Hypertrophic

5. DIVERTICULA 50% Sigmoid 40% Ascending Rare in Transverse 10% Throughout Colon Do Not Occur in Rectum Occur Due to Colonic Pressures as High as 90mm Hg

6. DIVERTICULITIS Misnomer- Should Be Peri-Diverticulitis Occlusion of Neck of Diverticulum ↓ Distention With Secreted Mucus ↓ Venous Gangrene ↓ Perforation Into Mesocolon

7. SYMPTOMS Left Lower Quadrant Pain Radiation to Suprapubic, Groin, Back Alteration in Bowel Habits Constipation or Diarrhea Fever, Chills, Urinary Urgency No Rectal Bleeding

8. PHYSICAL FINDINGS Depends on Site of Perforation Amount of Contamination Involvement of Adjacent Organs Left Lower Quadrant Tenderness, Guarding Tender Left Lower Quadrant Mass Distention, Ileus Fluctuant Mass on Rectal, Vaginal Exam

9. CT SCAN Preferred Imaging Study Reveals Location of Infection Extent of Process Presence/Absence of Abcess Secondary Complications Allows Percutaneous Drainage

10. HINCHEY CLASSIFICATION Estimates Severity of Disease Stage I. Pericolic or Mesenteric Abcess II. Walled Off Pelvic Abcess III. Generalized Purulent Peritonitis IV. Generalized Feculent Peritonitis Based on Clinical and CT Information

11. UNCOMPLICATED DISEASE Treat With Antibiotics (Cipro and Flagyl) Avoid Morphine (Increases Intracolonic Pressure) Avoid Colonoscopy, Barium enema Symptoms Should Resolve <48 Hours <25% Have Recurrent Attacks 6% Recovered Patients Need Operation Long-Term- High Fiber Diet

12. OPERATION Complicated Diverticulitis After Two or More Episodes Electively After Abcess Drainage Resection With Anastamosis Resection With Hartmann’s Procedure and Colostomy Resect Only Involved Bowel, Not All Diverticula

13. SIGMOID-URINARY FISTULAS Pneumaturia, Fecaluria Frequent Urinary Tract Infections CT Scan- Air in Bladder Cysto- Bullous Edema, Cystitis Antibiotics, One Stage Colon Resection, Possible Need for Repair of Bladder

14. PERITONITIS Two Causes- 1. “Free Perforation”- Colon to Mesocolon to Free Peritoneum- Hinchey IV 2. Rupture of Abcess- Hinchey III Develop Acute Abdomen Often Free Air on Abdominal Film, CT Requires Emergency Operation

15. OBSTRUCTION Rarely Occurs Two Causes 1. Chronic Stricture Due to Progressive Disease 2. Small Bowel Obstruction Due to Adhesion of Intestine to Inflammatory Process Both Need Operation