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A1-G Surg Note Large Bowel > Diverticular Disease of the Colon > Flashcards

Diverticular Disease of the Colon Flashcards

1
Q

Colonic diverticula , True or False explain

A

> not true diverticula
do not involve all layers of the bowel wall
only consist of mucosa and submucosa protruding through the muscularis propria.

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2
Q

what Cause it

A

> Intraluminal pressure cause herniation of mucosa through weak points of the muscle layer, where intramural branches of the vasa recta penetrate

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3
Q

Contributing factors that cause increased intraluminal pressure

A
  • Low-fiber diet
  • Small-caliber stools
  • Constipation
  • Consumption of red meat
  • Overweight and obesity
  • Physical inactivity
  • Smoking
  • (NSAIDs)
  • positive family history
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4
Q

Most Common Location

A

In Western countries > sigmoid colon

Asia > right-sided location is common.

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5
Q

what causes Diverticulitis ?

A

combination of poorly understood factors

> bacterial stasis
the presence of a fecalith
altered microbiome
impaired mucosal barrier function
subsequent inflammatory cascade.

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6
Q

What causes segmental colitis associated with diverticulosis (SCAD)

A

> inflammatory bowel disease, suggesting an autoimmune etiology

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7
Q

What causes Diverticular bleeding

A

originates from ruptured vasa recta at either the dome or neck of the diverticulum and is arterial.

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8
Q

Diverticular bleeding is more likely to occur in right-sided diverticular disease, Why ?

A

> diverticula of the right colon typically have a wider lumen, exposing a larger mucosal surface area to luminal stress, along with a thinner colonic wall.

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9
Q

Uncomplicated acute diverticulitis in Sigmoid Triad

A

> left lower quadrant pain
fever
leukocytosis.

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10
Q

What are the Complications ?

A
  • Abscesses 30%
  • Fistula 14%
  • Free perforation with peritonitis in 1% to 2%
  • Stricture with subsequent bowel obstruction is uncommon.
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11
Q

How would You Diagnose ?

A

(CT) Abdomen/Pelvis with IV Oral Contrast
> Mainstay imaging modality for acute diverticulitis and complications. A CT of the abdomen and pelvis with intravenous and oral contrast

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12
Q

Patients with contrast allergy ?

A

> Noncontrast CT or

Alternatives > MRI or US, particularly in the pregnant patient

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13
Q

Ultrasonography features ?

A
  • Hypoechoic colonic wall with a fecalith obstructing the diverticulum
    > Adjacent bowel wall, and mesenteric edema, which may indicate abscess formation.
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14
Q

Hinchey classification

A

see

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15
Q

Uncomplicated diverticulitis Vs Complicated diverticulitis

A

Uncomplicated > (Stage 0 or Ia) are restricted to the colon only

Complicated > beyond the colon, involving the peritoneum and pericolic structures

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16
Q

Tx for Uncomplicated

A

-If symptoms limit oral intake > fluid resuscitation and bowel rest
-gradually advancing to a low-residue diet
-ABx > Cover gram-negative and anaerobic bacteria

> ciprofloxacin plus metronidazole
or levofloxacin plus metronidazole

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17
Q

If there is Escherichia coli resistance to fluoroquinolones

A

> amoxicillin-clavulanate monotherapy
or
trimethoprim-sulfamethoxazole plus metronidazole

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18
Q

Recent Studies showed What regarding Abx ?

A
  • no difference in patient outcome comparing treatment with antibiotics versus fluid resuscitation only.
  • significantly higher rate of adverse events were associated with antibiotic treatment.
  • no difference in recurrence rates, complications, surgical treatment rates for the disease, and quality of life between the patient groups.
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19
Q

How long Abx

A
  • a 4-day course of intravenous antibiotics was as effective as a 7-day course
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20
Q

When to repeat Ct ?

A

If a patient’s clinical status does not improve after 5 days of treatment with persistent fever, leukocytosis, and elevated acute-phase proteins (C-reactive protein) > To Rule out Abscess

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21
Q

What to Do after Tx, What are the Percentages of Malignancies ?

A

uncomplicated : (< 2%) of occult colonic malignancy

complicated : 8% to 11 %.

Colonoscopy is typically performed 6 weeks after symptom resolution

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22
Q

When to consider elective colon resection

A

-recurrent episodes affecting quality of life
-smoldering disease
-immunocompromise

23
Q

What size of abscess to consider Drainage ?

A

antibiotics : Abscess ≤ 3 cm in size, Stable patient

percutaneous drainage : Abscesses > 3 cm or patients who do not respond to antibiotic treatment alone

24
Q

Methods of percutaneous drainage ?

A

transabdominal
transgluteal for pelvic abscesses
transvaginal
Transrectal

25
Q

Management of acute diverticulitis.

A

see

26
Q

When to remove Drain ?

A
  • Decreasing white blood cell and drain output to < 30 mL/ day
  • Drain contrast study will show the size of the residual abscess cavity and whether there is a communication to the colon
27
Q

In case of failure for Stage IB and II

A

surgery is indicated

> urgent abscess drainage and colectomy
with primary anastomosis and proximal diversion.

28
Q

How to distinguish III and IV ?

A

cannot be distinguished from one another clinically

Diagnosis in Surgery

29
Q

Definition of Hinchey III and IV

A

-III > occult colonic diverticular perforation with abscess formation and subsequent abscess rupture

-IV > free perforation of a diverticulum with peritoneal fecal contamination

30
Q

higher mortality rates up to 53% were found in patients with two or more of the following risk factors:

A
  • age > 80 years
  • ASA class 4 or 5
  • Elevated serum creatinine (> 1.2 mg/ dL)
  • and Hypoalbuminemia (< 2.5 g/ dL).
31
Q

Two types of colectomy can be performed:

A

(1) resection with primary anastomosis with or without proximal diversion (loop-ileostomy)

(2) resection with discontinuity and a Hartmann rectal stump and proximal end colostomy.

32
Q

Why there is a decrease in hartmanns ?

A

-Bowel reconstruction with closure of an end colostomy after a Hartmann procedure is associated with higher morbidity compared with closure of a loop ileostomy after primary anastomosis with proximal diversion

-high-risk patients who are at substantial risk of anastomotic leakage and major complications often never undergo the second operation of colostomy closure and Hartmann takedown.

33
Q

The decision on whether bowel continuity should be restored after resection based on ?

A

presence of shock
hemodynamic stability
immunosuppression
age
Intraoperative findings
(quality of tissue, presence of pan-abdominal inflammatory changes)

34
Q

An alternative to bowel resection in case of perforated diverticulitis ?

A

laparoscopic lavage with drain placement

Not recommended with feculent perforation (Hinchey IV). considered in select patients with purulent peritonitis (Hinchey III)

Associated With High Recurrent Surgical Re-Intevention , and subsequent abscess formation

35
Q
A
36
Q

Diverticular Stricture

A

-result from chronic inflammation in patients with smoldering or recurrent diverticular disease

-underlying malignancy must always be suspected

-if colonoscopy cannot be performed preoperatively to confirm the diagnosis > oncologic resection of the diseased colonic segment with lymph node clearance

37
Q

MC Diverticular Fistula

A

colovesical fistulas representing half of all fistulas.

38
Q

Other Fistulas ?

A
  • Colocutaneous fistulae From IR drain placement for
    abscess drainage
  • Colovaginal fistulas
    occur in women with Hx of hysterectomy
  • Rarely coloenteric or colouterine fistulas.
  • Colonoscopy > performed to Rule out Crohns or Malignancy
39
Q

In acute situation, You decided for Surgery , what to do pre op ?

A
  • important to mark the patient for a possible stoma site in the sitting position and to avoid skin folds and creases.
  • In obese individuals, the upper abdomen may provide a thinner abdominal wall, with easier stoma creation.
40
Q

Common Surgical Themes

A

1-Work from normal to abnormal
Begin dissection proximally, freeing up retroperitoneal structures superiorly and slowly working toward the area of inflammation
2- Medial to Lateral or Lateral to Medial
3- Visualize the left ureter, Consider ureteral stents, use of indocyanine green in ureteral stents for easy intraoperative visualization.
4- If not performing an anastomosis, resect the area of perforation > no need to go down lower to the rectum itself
5- If performing an anastomosis, the distal part of the colorectal anastomosis should lie within the upper rectum.
6- If extra colonic length is needed > Mobilize the splenic flexure and the IMV or IMA may need to be divided
7- The proximal line of transection should be in soft pliable bowel
8- If there is a dense inflammatory scar around the rectum, the rectum may need to be mobilized to allow a circular stapler to pass

41
Q

How to Locate the Upper Rectum

A

This is most easily located as the area where the colonic tenia confluence.

42
Q

If an anastomosis is made in the sigmoid colon ?

A

there is an up to 25% recurrence rate.

43
Q

Do you have to remove all Diverticular Colon ?

A

All of the diverticula-bearing colon does not need to be removed

44
Q

In case of bowel reconstruction with primary anastomosis, How its Done ?

A

-end-to-end circular stapler > create a double-stapled or triple-stapled anastomosis

-If there is a lot of edema or an inability to pass a stapler transanally > hand-sewn colorectal anastomosis

45
Q

Most Common Surgical Errors

A
  1. No preoperative stoma marking
  2. Anastomosis performed in the distal sigmoid colon
  3. Attempt to resect all colonic diverticula
  4. Very low Hartmann procedure performed, making subsequent closure more difficult
46
Q

diverticular bleeding present as

A
  • bright red blood per rectum
  • hematochezia
  • melena

Risk factors > NSAIDs , thrombocyte aggregation inhibitors, and anticoagulants, which is common among the elderly.

47
Q

When to Transfuse Blood

A

-hemoglobin level of 6 g/ dL absolutely indicates the need for a blood transfusion in the acute setting.

-Patients with a history of cardiovascular disease should receive blood at an Hb level of 8 g/ dL, and a level of 10 g/ dL should be maintained.

48
Q

What to do with Antiplatelets and Anticoagulation

A
  • Aspirin > can be continued, even perioperatively
  • Patients with a low thrombotic risk under warfarin therapy > reverse using prothrombin complex and vitamin K
    warfarin > restarted after an interval of 7 days.
  • In case of high thrombotic risk (mechanical heart valve, atrial fibrillation with a prosthetic heart valve or mitral stenosis, recent venous thromboembolic event [within prior 3 months]) > pausing warfarin has to be evaluated carefully.
  • heparin can be considered as a transitional solution in an emergency setting > monitoring (PTT) every 6 hours
49
Q

Diagnosis ?

A
  • colonoscopy
  • CT-A
50
Q

Endoscopic Strategies for Diverticular Bleeding

A
  • Colonoscopy performed within 24 hours
  • Identify source of bleeding and hemostatic intervention.
  • Need bowel preparation

Endoscopic treatment :
-epinephrine injection (1: 10,000, 1– 2 mL aliquots)
-bipolar cautery
- endoclipping
- band ligation
- application of topical hemostatic agents (e.g., Hemospray).

51
Q

Radiologic Strategies for Diverticular Bleeding

A
  • detect bleeding rates of 0.3 to 0.5 mL/ min.
  • For unsuccessful endoscopic evaluation, recurrent bleeding, or clinical instability
  • Selective angioembolization can be performed via vasopressin infusion or coil embolization
52
Q

Surgical Strategies for Diverticular Bleeding

A

Indications :
- Persistent or recurrent bleeding that cannot be managed via either endoscopic or angiographic
- transfusion of 6 units of blood within 24 hours to maintain a hemoglobin level
- persistent bleeding for 72 hours
- bleeding recurrence after initial treatment.

53
Q

If the source of bleeding cannot be identified preoperatively,

A

> subtotal colectomy with end ileostomy should be considered

Or if stable Patient > ileorectal anastomosis can be considered.

54
Q

Do you Consider Elective Colon Resection after Bleeding ?

A

-Overall Rebleeding Rate 4-42%

  • Prophylactic elective resection after initial bleeding in patients at high-risk for rebleeding episodes can be considered.

A1-G Surg Note Large Bowel (6 decks)

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