353: Diverticular Disease and Common Anorectal Disorders

Question 1

Differentiate the two types of diverticula : True and False (Pseudo diverticula)

Answer 1

True diverticulum: Sac like herniation of ENTIRE bowel wall

Pseudo diverticulum: Protrusion of the mucosa and submucosa through the muscularis propria of the colon

Question 2

Part of the colon that diverticulum commonly affects

Answer 2

LEFT and sigmoid colon
Asian: 70% are RIGHT colon and cecum

RECTUM always spared

Question 3

Most common cause of hematochezia in patients > 60 years

Answer 3

Hemorrhage from colonic diverticulum

Question 4

Profile of patients at increased risk of bleeding diverticula

Answer 4

Hypertensive
Atherosclerosis
Regular use of ASA and NSAIDS

Question 5

T or F: In order to stop a bleeding diverticular, surgery will always be the definitive treatment

Answer 5

False

Most bleeds are self-limited and stop spontaneously with bowel rest.
Rebleeding risk is 25% in lifetime

Question 6

T or F: 75% of diverticular diseases presents with fever.

Answer 6

True

Uncomplicated: abd pain, fever, leukocytosis, anorexia/obstipation

Complicated (25%): abscess, perforation, stricture, fistula

Question 7

Best modality for diagnosis of diverticulitis

Answer 7

CT scan

Findings: Sigmoid diverticula, thickened colonic wall >4mm and inflammation within periodic fat +/- collection of contrast material or fluid

Question 8

T or F: Suspected diverticulitis not associated with leukocytosis or fever is not diverticular disease.

Answer 8

True

Question 9

Differentials of diverticular disease

Answer 9

1. Ovarian cyst
2. Endometriosis
3. Acute appendicitis
4. Pelvic inflammatory disease

Question 10

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?

Answer 10

6 weeks

Question 11

Staging system developed to predict outcomes following surgical management of complicated diverticular disease

Answer 11

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

Question 12

Common locations of fistula formation in complicated diverticular disease

Answer 12

Cutaneous
Vaginal
Vesicle

Question 13

Presence of air in urinary stream

Answer 13

Pneumaturia

Question 14

Presents with passage of stool through the skin or vagina

Answer 14

Complicated diverticular disease

Question 15

Fistula common to women who have undergone hysterectomy

Answer 15

Colovaginal fistulas

Question 16

Treatment of ASYMPTOMATIC diverticular disease

Answer 16

Diet alterations

Fiber enriched diet: 30g of fiber each day

Question 17

T or F: Incidence of complicated diverticular disease are increased in patients who smoke.

Answer 17

True

Question 18

Treatment of SYMPTOMATIC UNCOMPLICATED diverticular disease with confirmation of inflammation and infection within the colon

Answer 18

Antibiotics

Bowel rest

Question 19

Antimicrobial regimen for diverticular disease

Answer 19

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

Question 20

Treatment with this drug decrease recurrence of symptomatic disease

Answer 20

Mesalazine

Question 21

Probiotics beneficial to diverticulitis

Answer 21

Lactobacillus acidophilus

Bifidobacterium strains

Question 22

Goals of surgical management of diverticular diseases

Answer 22

1. Controlling sepsis
2. Eliminating complications (e.g. fistula or obstruction)
3. Removing diseases colonic segment
4. Restoring intestinal continuity

Question 23

Conditions that increases the risk of perforation fivefold during a recurrent attack of diverticular disease

Answer 23

1. On immunosuppresive therapy
2. Chronic renal failure
3. Collagen-vascular disease

Question 24

Operative procedure for each Hinchey Stage (Table 353-3)

Answer 24

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

Question 25

Contraindications to percutaneous drainage

Answer 25

No percutaneous access route
Pneumoperitoneum
Fecal peritonitis

Question 26

Procedure that involves resection of the sigmoid colon with end colostomy and rectal stump

Answer 26

Hartmann’s procedure

Question 27

T or F: Retained segment of diseased rectosigmoid colon is associated with twice the incidence of recurrence.

Answer 27

True

Question 28

T or F: Rectal prolapse (Procidentia) is 6 times more common in men than in women.

Answer 28

False

Women > 60 years

Question 29

Children presenting with prolapse should undergo what test?

Answer 29

Sweat chloride test

Question 30

Circumferential, full-thickness protrusion of the rectal wall through the anal orifice

Answer 30

Rectal prolapse (procidentia)

Question 31

Known for radial grooves rather than circumferential folds around the anus and due to laxity of the connective tissue between submucosa and underlying muscle of anal canal

Answer 31

Mucosal prolapse

Question 32

If rectal prolapse is associated with chronic constipation, what tests should the patient undergo?

Answer 32

1. Defecating proctogram

2. Sitzmark study

Question 33

Result of attempting to defecate against a closed pelvic floor

Answer 33

Anismus or Nonrelaxing puborectalis

Question 34

Demonstrates retention of >20% of markers on abdominal xray 5 days after swallowing

Answer 34

Sitzmark study

Question 35

Treatment of rectal prolapse

Answer 35

Stool-bulking agents
Fiber supplementation

Mainstay: Surgical correction
Approaches: Transabdominal and Transperineal

Question 36

Common transperineal approaches

Answer 36

1. Transanal proctectomy (Altmeier procedure)
2. Mucosal proctectomy (Delorme procedure)
3. Placement of Tirsch wire encircling the anus

Goal: remove redundant rectosigmoid colon

Question 37

Common transabdominal approaches

Answer 37

Presacral suture or mesh rectopexy (Ripstein) with (Frykman-Goldberg) or without resection of the redundant sigmoid