Diverticular disease Flashcards
Histology – Large Intestine
Wall- enterocytes and goblet cells
Wall
Enterocytes
Absorptive cells – water, salts, and vitamins produced by intestinal bacteria
Goblet cells
Secrete mucous
Aids in the movement of feces
Protects the intestine from the effects of acids and gases produced by enteric bacteria
Anatomical Features
Bacterial Flora
The plethora of bacteria that lives in the large intestine
700 species that are nonpathogenic if they remain in the gut lumen
Functions:
Facilitate chemical digestion and absorption
Synthesize vitamins: biotin, vitamin K, vitamin B5
Deficiency of intestinal bacteria
Poorly regulated immune system and gut function
Association with autoimmune and inflammatory conditions
Diverticulosis
general
Presence of multiple (false) diverticula
Saclike pouch of colonic mucosa and submucosa that protrudes through the muscular layer of the colon
Measure 3-10 mm in size
Incidence increases with increasing age
75% of patients >80 years
Left-sided disease is most common in the United States
Diverticulosis
Sx
Asymptomatic (80%)
Detected incidentally on colonoscopy or barium enema
Symptomatic → nonspecific GI symptoms
Abdominal pain, bloating, constipation, diarrhea, passage of mucus from the rectum
Diverticulosis
Pathogenesis
Intraluminal pressure causes herniation of the mucosa and submucosa through weak areas in the colon wall
Diverticula occur in these weak spots (where vasa recta or nutrient vessels penetrate the muscular layer)
Diverticulosis in most patients involves thesigmoid (most common site)and the descending colon
Diverticulosis
Complications:
Diverticular bleeding – most likely to occur in the ascending colon (thinner walls)
Diverticulitis
Diverticulosis
RF
Presence of disease:
Diet:
Low fiber
High fat
Red meat
Direct correlation between red meat consumption per week
Seeds and nutsareNOTrisk factors
Obesity
Physical inactivity
RF of Complicated diverticular disease
Genetic disorders:
Marfan syndrome
Ehlers-Danlos syndrome
Scleroderma
Smoking
Diverticular Bleeding
general
Most common cause of brisk lower GI bleeding (50%) in adults
Occurs when a small artery located within a diverticulum is eroded and bleeds into the colon
Presents as abrupt painless hematochezia without concomitant diverticulitis
NSAID usage increases the risk of hemorrhage
bleeding most likely from R side bc ascending coloon has thinner walls
diverticular bleeding
causes
Causes:
Local trauma from impacted feces in a diverticulum that can erode the adjacent vessel
Enlargement of the diverticulum that can stretch and ultimately tear the vessel
Diverticulitis
general
Complication of diverticulosis
Painful inflammation with or without infection of a diverticulum
Classified as:
Uncomplicated and complicated
Incidence:
4% of those with diverticulosis develop diverticulitis
< 50 years – most common in ♂
> 50 years – most common in ♀
Increased risk in patients with HIV or undergoing chemotherapy
diverticulitis
patho
Increased intraluminal pressure and/or thickened food particles contribute to the erosion of the diverticular wall
Inflammation
Focal ischemia and/or necrosis (diverticulitis) develop
Possible micro- or macro-perforations
Bacterial translocation
Passage of bacteria from the gastrointestinal (GI) tract to extraintestinal sites
diverticulitis
Uncomplicated
No associated complication(s)
75-85% of diverticulitis cases
Diverticulitis
Complicated
(Complications)
Presence of:
Diverticular abscess (most common)
Obstruction
Free perforation
Fistula (frequently with the bladder)
Diverticular stricture
diverticulitis
Sx
Abdominal pain
Constant
Left lower quadrant (LLQ) - most common
Suprapubic – on occasion
Urinary urgency (from bladder irritation)
Constipation or diarrhea
Fever
Nausea/vomiting
diverticulitis
PE signs
Complicated
Tender to palpation over the affected area(s)
Rebound tenderness → local peritoneal irritation
Fever and tachycardia → complicated disease
Diffuse guarding and peritonitis → perforation
diverticulitis
Labs/tests
Digital rectal exam with FOBT (-/+)
Labs
Elevated WBC count (with left shift)
Lactic acid – concern for complicated disease
diverticulitis
imaging and findings
CT scan of the abdomen and pelvis with contrast
Diverticula
Colonic wall thickening (> 4 mm)
Pericolonic fat stranding
Micro-perforations (small gas bubbles next to the colon wall)
If complications are present:
Abscess: fluid collection(s) with necrotic debris or air-fluid levels
Fistula: air collection noted within other organs
Obstruction: dilated bowel loops
Perforation: free air noted
MRI
Alternative for pregnant and young patients
diverticulitis
Colonoscopy
Contraindicated during an acute episodeof diverticulitis due to increased risk of perforation
Recommended 6–8 weeks after resolution of the acute episode:
Establish the extent of the disease
Rule out other diagnoses
Malignancy
diverticulitis
Uncomplicated Tx
Varies with severity of disease
Uncomplicated disease:
Bed rest at home
Liquid diet for ~2-3 days
Reassessment with PCP in 2-3 days
complicated diverticulitis
general Tx
Complicated disease:
Hospitalized – surgical consultation
NPO
IV fluids
Pain management
diverticulitis
pharm Tx
Complicated disease, immunosuppressed patients, pregnancy, patients with significant comorbidities, age > 70 years
Cover gram-negative rods and anaerobic bacteria (ciprofloxacin and metronidazole)
Treatment for 7-10 days
diverticulitis
Abscess drainage
Indications (2)
Indicated for an abscess > 3 cm in diameter or abscess that does not resolve with antibiotics
CT-guided percutaneous procedure
Endoscopic ultrasound-guided procedure
diverticulitis
Segmental colectomy
Uncomplicated disease
Case-by-case evaluation after a second episode
Complicated disease
Recommended after the first episode
Immediate re-anastomosed ends in healthy patients without perforation, abscess, or significant inflammation
Temporary colostomy with anastomosis performed in a subsequent surgery after inflammation resolves
diverticulitis
Hartmann’s procedure
Gold standard for emergent cases
Also known as a proctosigmoidectomy
Resection of involvedcolon segment (and sometimes the rectum) with end colostomy
Remaining part of the rectum is sealed (Hartmann’s pouch)
The remining pert of the colon has a new outlet (colostomy)
Reversal of colostomycan be performed in 3–6 months
