353: Diverticular Disease and Common Anorectal Disorders Flashcards
Differentiate the two types of diverticula : True and False (Pseudo diverticula)
True diverticulum: Sac like herniation of ENTIRE bowel wall
Pseudo diverticulum: Protrusion of the mucosa and submucosa through the muscularis propria of the colon
Part of the colon that diverticulum commonly affects
LEFT and sigmoid colon
Asian: 70% are RIGHT colon and cecum
RECTUM always spared
Most common cause of hematochezia in patients > 60 years
Hemorrhage from colonic diverticulum
Profile of patients at increased risk of bleeding diverticula
Hypertensive
Atherosclerosis
Regular use of ASA and NSAIDS
T or F: In order to stop a bleeding diverticular, surgery will always be the definitive treatment
False
Most bleeds are self-limited and stop spontaneously with bowel rest.
Rebleeding risk is 25% in lifetime
T or F: 75% of diverticular diseases presents with fever.
True
Uncomplicated: abd pain, fever, leukocytosis, anorexia/obstipation
Complicated (25%): abscess, perforation, stricture, fistula
Best modality for diagnosis of diverticulitis
CT scan
Findings: Sigmoid diverticula, thickened colonic wall >4mm and inflammation within periodic fat +/- collection of contrast material or fluid
T or F: Suspected diverticulitis not associated with leukocytosis or fever is not diverticular disease.
True
Differentials of diverticular disease
- Ovarian cyst
- Endometriosis
- Acute appendicitis
- Pelvic inflammatory disease
The parallel epidemiology of colorectal cancer and diverticular disease provides enough concern for endoscopic evaluation before operative management.
When should colonoscopy be performed after an attack of diverticultis?
6 weeks
Staging system developed to predict outcomes following surgical management of complicated diverticular disease
Hinchey classification system
Stage I : Perforated diverticulitis (PD) with confined paracolic abscess
II: PD that has closed spontaneously with distant abscess formation
III: Noncommunicating perforated diverticultis with fecal peritonitis
IV: Perforation and free communication with peritoneum resulting in fecal peritonitis
Common locations of fistula formation in complicated diverticular disease
Cutaneous
Vaginal
Vesicle
Presence of air in urinary stream
Pneumaturia
Presents with passage of stool through the skin or vagina
Complicated diverticular disease
Fistula common to women who have undergone hysterectomy
Colovaginal fistulas
Treatment of ASYMPTOMATIC diverticular disease
Diet alterations
Fiber enriched diet: 30g of fiber each day
T or F: Incidence of complicated diverticular disease are increased in patients who smoke.
True
Treatment of SYMPTOMATIC UNCOMPLICATED diverticular disease with confirmation of inflammation and infection within the colon
Antibiotics
Bowel rest
Antimicrobial regimen for diverticular disease
Trimethoprim/Sulfamethoxazole OR
Ciprofloxacin and Metronidazole
3rd gen penicillin such as IV piperacillin or oral penicillin/clavulanic acid
if nonresponders: Add Amoxicillin
Duration: 7-10 days
Treatment with this drug decrease recurrence of symptomatic disease
Mesalazine
Probiotics beneficial to diverticulitis
Lactobacillus acidophilus
Bifidobacterium strains
Goals of surgical management of diverticular diseases
- Controlling sepsis
- Eliminating complications (e.g. fistula or obstruction)
- Removing diseases colonic segment
- Restoring intestinal continuity
Conditions that increases the risk of perforation fivefold during a recurrent attack of diverticular disease
- On immunosuppresive therapy
- Chronic renal failure
- Collagen-vascular disease
Operative procedure for each Hinchey Stage (Table 353-3)
Hinchey Stage I: Resection with primary anastomosis w/o diverting stoma
II: Resection with primary anastomosis +/- diversion
III: Hartmann’s procedure vs diverting colostomy and omental pedal graft
IV: Hartmann’s procedure vs diverting colostomy and omental pedicle graft
