1. Diverticular disease of the colon

Question 1

Clinical terms:

Answer 1

• Diverticular disease: presence of symptomatic diverticula
• Diverticulosis: presence of diverticula without inflammation
• Diverticulitis: inflammation and infection associated with diverticula.
• false diverticula: are the majority in which the mucosa and muscularis mucosa have herniated through the colonic wall.
• Pulsion diverticula: results from high intramural pressure.
• Diverticular bleeding ca be massive but is self-limited
• True diverticula: comprise all layers of the bowel wall, are rare and are usually congenital in origin.

Question 2

epidemiology

Answer 2

• estimated that half of the population > 50y has colonic diverticula

Question 3

Where is the most common site of diverticula?

Answer 3

sigmoid colon

Question 4

etiology

Answer 4

• diverticulosis is thought to be an acquired disorder
• theory: lack of dietary fiber results in smaller stool volume, requiring high intraluminal pressure and high colonic wall tension for propulsion.
  chronic contraction then results in muscular hypertrophy and pulsing diverticula.
• a loss of tensile strength and a decrease in elasticity of the bowel wall with age
• > high fiber intake decreases the risk of diverticulosis.

Question 5

Inflammatory complications: diverticulitis: refers to?

Answer 5

inflammation and infection associated with diverticulum and is estimate to occur in 10 to 25% of ppl with diverticulosis.

Question 6

Inflammatory complications: diverticulitis: peridiverticular and peri colic infection results from?

Answer 6

a perforation (either macro or microscopic) pf a diverticulum.

Question 7

Inflammatory complications: diverticulitis: clinical manifestations:

Answer 7

left sided abdominal pain
with or without fever
leukocytosis
a mass may be present

Question 8

Inflammatory complications: diverticulitis: diagnosis & diffenrecial diagnosis

Answer 8

CT scan extremely useful for defining pericolic inflammation, phlegmon or abscess.
contrats enemas and/Or endoscopy are relatively contraindicated -> risk of perforation.
differential diagnosis: malignancies, ischemic colitis, infectious colitis and inflammatory bowel disease.

Question 9

Uncomplicated diverticulitis: characterized by?

Answer 9

left lower quadrant pain and tenderness.

Question 10

Uncomplicated diverticulitis: findings

Answer 10

CT findings include pericolic soft tissue stranding colonic wall thickening, and or phlegmon.

Question 11

Uncomplicated diverticulitis: TTT

Answer 11

• some patients will respond to outpatient therapy with broad-spectrum or oral antibiotics and a low residue diet. (antibiotics should be continued for 7 to 10 days)
• more severe pain, tenderness, fever and leukocytosis should be treated in the hospital with parental antibiotics and bowel rest. most patients improve within 48 to 72h.
  failure to improve -> suggests abscess formation.

Question 12

Uncomplicated diverticulitis: findings

Answer 12

CT -> useful & many pericolic abscesses can be drained percutaneously.

Question 13

Uncomplicated diverticulitis: complications

Answer 13

deterioration of patients’ condition and or the development of peritonitis -> indications for laparotomy.
most of patients will recover without surgery and 50 to 70% will have no further episodes.

Question 14

Complicated Diverticulitis: characterized by?

Answer 14

include diverticulitis with abscess, obstruction, diffuse peritonitis (free perforation), or fistulas between the colon and adjacent structures.

Question 15

Complicated diverticulitis: sequelae?

Answer 15

colovesical
colovaginal
coloenteric fistulas

Question 16

Complicated diverticulitis: Hinchey raging system?

Answer 16

describes the severity of complicated diverticulitis.

Question 17

Complicated diverticulitis: which are the stages?

Answer 17

• stage 1: colonic inflammation with an associated pericolic abscess
• stage 2: colonic inflammation with a retroperitoneal or pelvic abscess
• stage 3: purulent peritonitis
• stage 4: fecal peritonitis

Question 18

Complicated diverticulitis: on what depend the ttt?

Answer 18

depends on the patient’s overall clinical condition and the degree of peritoneal contamination and infection.

Question 19

Complicated diverticulitis: TTT

Answer 19

-small abscess: (<2cm diameter): parenteral antibiotics
-larger abscess: best treated with CT-guided percutaneous drainage.
the majority of those patients will require resection, but percutaneous drainage may allow a one-stage, elective procedure.

Question 20

Complicated diverticulitis: surgical TTT:

Answer 20

• patients with an abscess which is inaccessible to percutaneous drainage, if the patients condition deteriorates or fails to improve or if the patients presents with a free intra-abdominal air or peritonitis -> urgent or emergent laparotomy may be required
• patients with small, localized perioclioc or pelvis abscess (stage 1 and 2) -> sigmoid colectomy with a primary anastomosis.
• patients with a larger abscess, peritoneal soiling, or peritonitis -> sigmoid colectomy with end colostomy and Hartmann pouch.

Question 21

Complicated diverticulitis: complications

Answer 21

5% of patients develop fistulas between the colon and adjacent organ.
-> colovesical fistula most common
-> colovaginal and coloenteric fistulas.
-> colocutaneous fistulas are rare
two points in the evaluation of fistulas are to define the anatomy of the fistulas and exclude other diagnosis

Question 22

Complicated diverticulitis: fistulas findings

Answer 22

• contrats enemas and or small bowel studies are extremely useful in defining the Course of the fistula
• CT scan can identify associated abscesses and masses

Question 23

Complicated diverticulitis: differential diagnosis

Answer 23

malignancy
Crohn’s disease
radiation induced fistulas

Question 24

Hemorrhage from a diverticulum

Answer 24

-> results from erosion of the peridiverticular arteriole -> massive hemorrhage.
In elderly ppl -in whom both diverticulosis and angiodysplasia are common> gastrointestinal hemorrhage
- in 80% of cases bleeding stops spontaneously.