1. Robert Zaid PGY-1 October 24, 2005 Genesys Regional Medical Center
Diverticulitis
Robert Zaid PGY-1
October 24, 2005
Genesys Regional Medical Center

2. Barcelona - Gaudi

3. Diverticulitis Outline
Definition
Pathophysiology
Epidemiology
Clinical presentation
Differential
Imaging
Laboratory
Treatment
Reasons for surgery

4. Diverticulitis Definition
Diverticula
Etiology
Outpouchings
Occur in areas weak and under stress
Prolapse of mucosa and submucosa may occur.
Location
Arteries penetrate the muscularis to reach the submucosa and mucosa.
Diverticula form through entire colon
Left colon
Sigmoid (most common)
Right sided (uncommon)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

5. Diverticulitis Definition
Fecalith becomes impacted in a diverticulum
Erosion through the serosa
Perforation
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

6. Citadel Park

7. Diverticulitis Pathophysiology
Diverticula
Acquired or congenital
Can affect small or large intestine
May be related to an increase in intramural pressure
Occurs in the weakest areas of the colonic wall
Adjacent to the vasa recta
Mesenteric side of the colon
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis,

8. Diverticulitis Pathophysiology
Theories
Deficiency in dietary fiber
Western diet
Decreased fecal bulk
Narrowing of the colon
Small fecal mass
Increased intraluminal pressure needed to move material
Loss of tensile strength
Decrease in elasticity
Proof?
High fiber diet appears to decrease incidence
Brunicardi, C., F., Schwartz principles of surgery, pp , 8th edition, 1999

9. Diverticulitis Pathophysiology
Diverticula
False diverticula (pulsion)
Herniation through colonic wall
Mucosa
Muscularis
Occur between tenia coli
Points of weakness
High intraluminal pressure
Bleeding is self limiting
True diverticula
Rare and usuall congenital
Comprise all layers of bowel wall
Brunicardi, C., F., Schwartz principles of surgery, pp , 8th edition, 1999

10. Diverticulitis Pathophysiology
Inflammation in and around a diverticulum
Stagnation of nonsterile inspissated fecal material (fecalith)
May compromise the blood supply
Cusing inflammatory erosion of the mucosal lining
Perforation
Intramural abscess
Fibrinous exudate
Abscess formation
Local adhesions
Peritonitis
Sealed-off abscesses
Contained sinus tracts
Fistulas
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis,

11. La Familia

12. Diverticulitis Epidemiology
Frequency in US
Diverticular disease
5% of population at age 40
33-50% of population older than 50
80% of population older than 80
Diverticulitis
10-20% of patients with diverticular disease
Frequency internationaly
Diverticulosis occurs in 0.2% of population
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis,

13. Diverticulitis Epidemiology
Mortality and Morbidity
20% require surgical therapy
Mortality rate of 7.7% (if peritonitis is present)
Race
Asians predisposed to right sided diverticulitis
Sex
No relationship
Age
Disease increases with age
Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis,

14. Diverticulitis Clinical Manifestations
Symptoms
Pain
Typically located in left lower quadrant
Subacute and constant pain
Right sided diverticulitis can occur (congenital?)
Fever
Almost invariably present
High-grade fever and sepsis
If perforation is not contained or
When the peritonitis is generalized
Constipation or loose stools may be reported
Rectal bleeding is unusual.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

15. Diverticulitis Clinical Manifestations
Fistulas occur in 5% of patients w/ complicated diverticulitis
Colovesical
Colovaginal
Coloenteric
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

16. Diverticulitis Differential Diagnosis
Lower abdominal pain, fever, and bloody diarrhea
Bacterial colitis (Shigella, Salmonella, Campylobacter)
Ischemic colitis
Inflammatory bowel disease
Generalized peritonitis
Acute abdomen
Gynecologic disorders
May be localized to the left lower quadrant (LLQ)
Acute severe abdominal pain
Perforation of an abdominal viscus
Peptic ulcer
Small bowel obstruction
Choledocholithiasis
Nephrolithiasis
Rupture and dissection of an abdominal aortic aneurysm
Subacute onset of pain
Intestinal ischemia
Cholecystitis
Pancreatitis
Diverticulitis
Crohn's disease
Appendicitis
Pain of a constant nature
Inflammatory disorders
Colicky pain occurs
Intestinal obstruction
Radiation of pain
Peptic ulcer disease
Biliary tract disease
Shoulder pain
Diaphragmatic irritation
Significant vomiting is seen with pancreatitis or obstruction of the stomach or small bowel.

17. Diverticulitis Laboratory
Leukocytosis
Common, nonspecific
Urinalysis
Protein or rare white blood cells may be found
Nonspecific
Fecal leukocytes
Should be sought if diarrhea is present
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

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19. Diverticulitis Imaging
Abdominal radiographs
May indicate
A displaced colon
Extraluminal gas
Colonic mucosal abnormalities
More helpful in excluding other potential causes of left lower quadrant pain.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

20. Diverticulitis Imaging
Abdominal CT
Test of choice
May demonstrate
Bowel wall thickening
Abscess formation
Diverticula
Diagnostic barium enema
Safe when carefully performed
Findings include
Spiculation of the mucosa
Spasm
Frank perforation
Abscess
Findings specific for diverticulitis, but may be hard to distinguish from carcinoma
CT and barium enema are complementary
Neither is 100% sensitive or specific.
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

21. Diverticulitis Imaging
Computed tomographic scan
Marked thickening of
Distal end of the descending colon
Inflammatory changes (straight arrow)
Extraluminal gas (curved arrow)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

22. Diverticulitis Imaging
Barium Enema
Colon with sinus formation
Shows multiple diverticula
Communicating sinus is clearly seen (arrow).
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

23. Diverticulitis Imaging
Endoscopic examination
Contraindicated with diverticulitis
Theoretical potential to exacerbate perforation
Can detect diverticulosis before or between attacks
Sigmoidoscopy
Appropriate when
Carcinoma or
Inflammatory bowel disease is highly suspected
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

24. Diverticulitis Imaging
Colonoscope
Wide-mouthed openings to diverticula
Colonoscopy may be difficult and hazardous when diverticula are large enough to admit the tip of the scope.
Beers, M., 2005, Merck Manual of Medical Information, Online version,

25. Street entertainers

26. Diverticulitis Treatment
Mild diverticulitis
Initially (symptoms usually disappear rapidly)
Rest
A liquid diet
Oral antibiotics
After a few days
Soft, low-fiber diet and take a daily psyllium (i.e. metamucil) seed preparation.
After 1 month
A high-fiber diet can be started
Severe symptoms— (perforation, peritonitis)
Admitted to hospital
Intravenous fluids and antibiotics
Bedrest
Nothing by mouth until the symptoms subside
About 20% of people who have diverticulitis require surgery because the condition does not improve.
Beers, M., 2005, Merck Manual of Medical Information, Online version,

27. Diverticulitis Treatment
Inpatient
Broad-spectrum antibiotics
Third-generation cephalosporin
Ceftriaxone 1.5mg intravenously daily
Anaerobic coverage
Metronidazole 250mg intravenously three times daily
At discharge
Oral antibiotics to complete 14 day course
Ciprofloxacin and Metronidazole)
Outpatient (mild disease)
Oral antibiotics (14 days)
Ciprofloxacin (500mg twice daily)
Metronidazole (250mg three times daily) for 14 days
Bowel rest
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

28. Diverticulitis Treatment
Colon carcinoma may mimic diverticulitis
Colonoscopy or sigmoidoscopy is recommended 4-6 weeks after recovery when surgery is not performed
Brunicardi, C., F., Schwartz principles of surgery, pp , 8th edition, 1999

29. Diverticulitis Treatment
Early surgical consultation is important
Especially in the presence of significant pain or
An acute abdomen
Percutaneous catheter drainage
If large abcess is present
Temporary
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

30. Diverticulitis Treatment
Some reasons for surgery
Colonic stricture
Bleeding
Fistula formation to
The small bowel
Colon
Bladder
Vagina
Surgcial resection
Warranted in reoccurrences (1/3 of all patients)
Sigmoid colectomy with anastamosis
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis

31. Diverticulitis Treatment
Hinchey staging
Stage I
Colonic inflammation
Pericolic abcess
Stage II
Retroperitoneal or
Pelvic abcess
Stage III
Purulent peritonitis
Stage IV
Fecal peritonitis
Percutaneous drainage?
If not….
Sigmoid colectomy w/ primary anastamosis
Stage I or II
Sigmoid colectomy w/ hartman pouch
Larger abcesses
Brunicardi, C., F., Schwartz principles of surgery, pp , 8th edition, 1999

32. Festivals

33. Diverticulitis Reasons for Elective Surgery
CONDITION
Two or more severe attacks of diverticulitis (or one severe attack in someone younger than 50)
Narrowing of the sigmoid colon (lower part of the large intestine) due to scarring
Persistent tender mass in the abdomen
X-ray showing suspicious changes in the sigmoid colon
Pain when urinating
Sudden abdominal pain in people taking corticosteroids
REASON
High risk of serious complications
May be cancer
May be a warning of impending fistula formation between the large intestine and the bladder
Large intestine may have ruptured into the abdominal cavity
Beers, M., 2005, Merck Manual of Medical Information, Online version,

34. Any questions?