1. Diverticula of the Alimentary Tract Aaron Sinclair, MD

2. Learning Objectives Differentiate between true and false diverticula. Review pathophysiologic development of different diverticula. Evaluate the locations of common diverticula of the alimentary tract. Assess different diagnostic modalities for diverticula. Discuss when treatment is indicated for diverticula.

3. Normal Anatomy

4. http://www.bing.com/images/search?q=false+ diverticulum&view=detailv2&qpvt=false+diver ticulum&id=7FF679420026BBF80510055167A0 720E75EDA50E&selectedIndex=0&ccid=cBNI2q eg&simid=608039890951996806&thid=OIP.M7 01348daa7a0c137b30f6bebf4532517o0

5. Diverticula of the Esophagus Upper Esophagus – Zenker’s Middle Esophagus – Traction Lower Esophagus – Epiphrenic

6. Upper Esophagus – Zenker’s Diverticulum False Diverticulum Upper Posterior Esophagus – Killian’s Triangle

7. http://emedicine.medscape.com/article/37415 3-overview Upper Esophagus – Zenker’s Diverticulum Etiology – unknown, ? Acid and Swallowing dysfunction. Age predominately > 60 Incidence 2/100,000

8. http://www.gastrolab.net/y0157.jpg Upper Esophagus – Zenker’s Diverticulum Diagnosis – preferred barium swallow Caution with endoscopy due to perforation risk

9. Zenker's Diverticulum Ryan Law,David A. Katzka, Todd H. Baron Published Online: September 19, 2013 http://dx.doi.org/10.1016/j.cgh.2013.09.016 Upper Esophagus – Zenker’s Diverticulum Treatment – Traditional Surgical Management – Endoscopic Cricopharyngeal Myotomy Symptom Improvement as high as 90% Recurrence in up to 35%

10. Middle Esophagus – Traction Diverticulum True Diverticulum Mediastinal lymphadenopathy scarring  traction

11. http://www.gastrohep.com/i mages/image.asp?id=720 Middle Esophagus – Traction Diverticulum Usually < 2 cm in size Treatment rarely needed unless complications occur – Fistulas – Occlusion

12. Lower Esophagus – Epiphrenic Diverticulum False Diverticula Rare =.015% of the population Occurs within 10 cm of Lower Esophageal Stricture

13. Lower Esophagus – Epiphrenic Diverticulum Etiology = GERD + Motility Dysfunction ? Treatment = typically not indicated if < 5 cm & asymptomatic Therapy: – Fundoplication (GERD) – Open Resection or Laparoscopic

14. Gastric Diverticulum True Diverticulum Rare -.04% Usually asymptomatic but can lead to complications: – Bleeding – Dyspepsia – Emesis

15. http://www.eurorad.org/eurorad/view_figu re.php?pubid=11721&figid=36787&nr=1&la ng=en Gastric Diverticulum Treatment – conservative for symptomatic patients only – Proton Pump Inhibitors Definitive Treatment – Gastrectomy of the Diverticulum

16. http://www.gastrolab.fi/videos/vid3065.jpg Duodenal Diverticula True or False Diverticula Common – 22% of population Most common location is 2 nd part Can lead to complications due to location – Obstuction Sphincter of Oddi – Impingement of Hepato- biliary tree

17. http://posterng.netkey.at/esr/viewing/index.p hp?module=viewing_poster&task=viewsection &pi=105730&ti=324613&searchkey= Duodenal Diverticula Diagnosis – Endoscopy – Small Bowel Follow Through – MRI or CT scan – Endoscopy Treatment – Asymptomatic – nothing – Dependent on symptoms http://www.gastrolab.fi/videos/vid3063.jpg

18. http://openi.nlm.nih.gov/imgs/512/211/29888 64/2988864_crg0004-0492-f03.png Jejunal and Ileal Diverticula False Diverticula Occur anywhere along the Jejunum or Ileum Typically on the mesenteric side of the bowel at blood vessel penetration Most are found incidentally Symptoms may include – Bleeding – Obstruction – Infection ?Bacterial overgrowth. Diverticulitis Jejunal Diverticulitis: A Rare Case of Severe Peritonitis. Sakpal SV, Fried K, Chamberlain RS - Case Rep Gastroenterol (2010)

19. Jejunal Diverticulosis: Findings on CT in 28 Patients Florian Fintelmann 1 Marc S. Levine Stephen E. Rubesin http://www.ajronline.org/doi/pdfplus/10.2214/AJR.07.3 087 AJR:190, May 2008 http://pillcamkorea.co.kr/boa rd/image_viw.asp?key=106&p age=5 Jejunal and Ileal Diverticula Diagnosis: – Capsule Endoscopy – Small Bowel Barium Contrast Follow Through Treatment – Antibiotics – Promotility Agents – Resection

20. http://emedicine.medscape.com/article/19477 6-overview#a2 Meckel’s Diverticula True Diverticula Rule of 2’s – 2% of the population – 2 feet from the ileocecal valve – 2:1 male predominance – 2% are symptomatic May have ectopic tissues Symptoms may include – Bloody Mucoid stools – Abdominal pain – Nausea and vomiting under age 6

21. Meckel’s Diverticula Diagnosis: – Adults – high degree of suspicion – technectium 99m scan – Children Ultrasound – Can fix intussusception - 90% CT Scan Treatment – Based on Age and Symptoms 5 fold increase in complications – Bowel Obstruction – Infection – Asymptomatic – remove Age <50 or young children Palpable abnormality Size >2 cm (length or base)

22. Colonic Diverticula False Diverticula Arteries penetrate the muscularis to reach the submucosa and mucosa – weak point

23. Colonic Diverticula Decreased fiber leads to an increase in colonic wall pressures. Low fiber  colonic wall hypertrophy LaPlace’s Law – Increased pressure at smaller diameter (sigmoid)

24. http://www.drugs.com/health- guide/diverticulosis-and- diverticulitis.html Colonic Diverticula Incidence – Age 4020% of all people – Age 8060% of all people 80% asymptomatic with diverticulosis 15% to 20%  diverticulitis 5% to 10%  diverticular bleeding Diagnosis – CT Scan – Endoscopy – Radionucleide Imaging – Barium Enema

25. Colonic Diverticula Treatment – Strong Associations Fiber – A Harvard study of 47,888 men demonstrates the role of dietary fiber. Men who consumed the most fiber were 42% less likely to develop symptomatic diverticular disease than their peers who consumed the least fiber. – Weak Associations Increasing Exercise Increasing Water Intake Decreasing Low Fat/High Meat Diet

26. References Aggerholm K, Illum P. Surgical treatment of Zenker's diverticulum. J Laryngol Otol. 1990 Apr;104(4):312-4. Aldoori et al. A Prospective Study of Dietary Fiber Types and Symptomatic Diverticular Disease in Men. J. Nutr. 128: 714–719, 1998 Choi JJ, Ogunjemilusi O, Divino CM. Diagnosis and management of diverticula in the jejunum and ileum. Am Surg. 2013 Jan;79(1):108-110 Fry R, Mahmoud N, Maron D, et al. Townsend: Sabiston’s Textbook of surgery. Rev. Ed. 19 th Edition, 1309-1314. Jacobs DO. Clinical Practice. Diverticulitis. N Engl J Med. 2007 Nov 15;357(20):2057-66. Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006 Feb 4;332(7536):271-5. Kilic A, Schuchert MJ, Awais O, et al. Surgical management of epiphrenic diverticula in the minimally invasive era. JSLS. 2009 Apr-Jun;13(2):160-4. Maish, M. Townsend: Sabiston’s Textbook of surgery. Rev. Ed. 19 th Edition,1023-1025. Martinez-Cecilia D, Arjona-Sanchez A, Gomez-Alvarez M, et al. Conservative management of perforated duodenal diverticulum: a case report and review of the literature.World J Gastroenterol. 2008 Mar 28;14(12):1949-51. Mohan P, Ananthavadivelu M, Venkataraman J. Gastric diverticulum. CMAJ. 2010 Mar 23;182(5):E226. Morris AM, Rogenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA. 2014;311(3):287-297 Mulder CJ, Costamagna G, Sakai P. Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy. 2001 Nov;33(11):991-7. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005 Mar;241(3):529-33. Shahedi K1, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013 Dec;11(12):1609-13. Strate LL. Lower GI bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am. 2005 Dec;34(4):643-64. Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol. 2011 Jul;25(7):385-9. Zani A, Eaton S, Rees CM, Pierro A. Incidentally detected Meckel diverticulum: to resect or not to resect? Ann Surg. 2008 Feb;247(2):276-81.