DIVERTICULITIS Flashcards
Diverticulum:
abnormal sac-like protrusion from the wall of a
hollow organ
Diverticulosis
presence of multiple diverticula
Diverticulitis
inflammation of diverticula
True (congenital) diverticuli:
contain all layers of colonic wall,
often right-sided
False (acquired) diverticuli:
contain mucosa and submucosa,
often left-sided
Colonic diverticula
protrusions of mucosa through the muscular
layer of the intestine. Because these mucosal herniations are
devoid of the normal muscular layers, they are pseudodiverticula
Diverticulosis
is the presence of multiple diverticula in the colon, resulting from long time consumption of low fiber diet. There is an increase in the intrabowel
pressure due to straining, constipation (which may be a result of low fiber diet) which causes mucosal outpouchings on the wall of the intestine
Epidemiology
5-50% of Western population,
o Lower incidence in non-Western countries. Rare in sub saharan African Blacks who consume a high
fiber diet
o M=F
o Prevalence is age dependent:
o 95% involve sigmoid colon (site of highest pressure)
o It is an acquired condition
Pathogenesis
high intraluminal pressures cause outpouching to occur at point of greatest weakness, most
commonly where vasa recta penetrate the circular muscle layer, therefore increased risk of hemorrhage.
Diverticula are herniations of mucosa at sites of penetration of the muscular wall by arterioles, on the
mesenteric side of the anti mesenteric taenia. When there is a large volume of fiber the contractile pressure
required to propel the feces forward is low. Instead, decreased amount of fibers in the colon causes
increased colonic pressures which are responsible for the herniations.
Where?
Sigmoid: 50% of patients with diverticulosis (it is the most frequent site of diverticulitis, too) à
SIGMOID DIVERTICULITIS NEEDS TO BE DISTINGUISHED FROM CANCER
o Descending colon: 40%
o Entire colon: 5 – 10%
o There is often hypertrophy of the muscular layers of the colonic wall associated with
diverticulosis.
RFs
lifestyle: low-fibre diet (predispose to motility abnormalities and higher intraluminal pressure),
inactivity, obesity. Decreased consumption of unprocessed cereals and increased consumption
of sugar and meat.
o muscle wall weakness from aging and illness (e.g. Ehler-Danlos, Marfan’s)
CLINICS
Uncomplicated diverticulosis: asymptomatic (70-80%)
o Episodic abdominal pain (often LLQ), bloating, flatulence, constipation, diarrhea
o Absence of fever/leukocytosis
o No physical exam findings or poorly localized LLQ tenderness
o Complications
§ diverticulitis (15-25%): 25% of which are complicated (i.e. abscess, obstruction, perforation, fistula)
§ bleeding (5-15%): PAINLESS rectal bleeding, 30-50% of massive lower GI bleeding.
§ diverticular colitis (rare): diarrhea, hematochezia, tenesmus, abdominal pain
§ Diverticular disease-associated colitis (DAC)- mucosal inflammation in a colon segment affected with DD with relative sparing of the
rectum and proximal colon.
TREATMENT
Uncomplicated diverticulosis: high fibre, education
o Diverticular bleed
§ initially workup and treat as any LGIB
§ if hemorrhage does not stop, resect involved region
DIVERTICULITIS
it is a condition brought on by infection or perforation of diverticula, which are bulges forming in the lower part of the large intestine or colon.
Where?
The sigmoid colon has this highest incidence of diverticula and it is the most frequent site for
involvement with diverticulitis.
EPIDEMIOLOGY
95% left-sided in patients of Western countries,
o 75% right-sided in Asian populations
PATHOGENESIS
Erosion of the diverticular wall by increased intraluminal pressure or inspissated food particles à
inflammation and focal necrosis à micro or macroscopic perforation à pericolonic inflammation
o Usually the inflammation is mild as the perforation is walled off by pericolic fat and mesentery;
o Possible complications include abscess, fistula (e.g. pneumaturia or fecaluria)12, or obstruction
(most often is insidious, but patients can occasionally have significant obstructive symptoms- usually
due to a phlegmon or abscess adhering to the small bowel)
Diverticulitis has a broad spectrum of severity (single episode, repeated episodes or fulminant
complicated disease characterized by life-threatening sepsis).
HINCHLEY
It is a classification regarding the abscesses formed from the
diverticula and aids in staging the diverticulitis
¨ Stage I: Pericolic or mesenteric abscess: wait-and-see management. If the
abscess cannot be drained or it is refractive to pharmacologic therapy, we
perform surgery
¨ Stage II: Walled-off pelvic abscess
¨ Stage III: Generalized purulent peritonitis
¨ Stage IV: Generalized fecal peritonitis
The classification is based on the CT examination images and is basic in order to
understand either the patient needs surgery or not.
§ Appropriate treatment must be individualized based on the severity of the disease
§ The Hinchey classification divides the particular perforations into four stages. Mortality
increases significantly in stages III and IV.
CLINICS
ranges from asymptomatic to generalized peritonitis
o We have three main symptoms: fever, bowel changes (e.g. constipation, paralytic ileus), and pain
o LLQ pain/tenderness (2/3 of patients) often for several days before admission. Possible radiation to
the suprapubic area, left groin, or back
The most common physical findings are:
Tenderness of the left lower abdomen
§ Alterations in bowel habits
§ Fever
§ Chills
§ Urinary urgency
§ Rectal bleeding is not usually associated
§ Other possible symptoms: constipation, diarrhea, N/V, urinary symptoms (with adjacent inflammation)
o The physical findings are dependent on
The site of perforation
§ Amount of contamination
§ Presence or absence of secondary infection of adjacent organs
o Complications (25% of cases)
Abscess: palpable tender abdominal mass.
Usually confined to the pelvis
¨ Significant pain, fever, and leukocytosis
¨ The abdominal, pelvic, or rectal examination may detect a tender, fluctuant mass
¨ CT scan, MRI, or ultrasound will confirm the diagnosis and location
Fistula: colovesical (most common), coloenteric, colovaginal, colocutaneous
A fistula to the skin, bladder, vagina, or small bowel is relatively frequent
¨ It forms one an Abscess is drained into an adjacent organ or into the skin
¨ The perforated diverticulum (source of infection) continues to supply the fistula (excising the disease sigmoid colon to stop
it)
¨ Symptoms: pneumaturia (passage of air through the urethra), fecaluria, and recurring urinary tract infections
¨ The most reliable test is CT, which may demonstrate air in the bladder. The barium enema will fail to reveal a fistula 50%
of the times. Cystoscopy usually reveals cystitis and bullous edema at the side of fistula: it is helpful to rule out cancer.
Generalized peritonitis due to perforation
Causes: They both require urgent operation
Feculent perforation: Diverticulum perforates into the peritoneal cavity and the perforation is not sealed:
peritoneal cavity is contaminated with feces
- Purulent perforation: Abscess that suddenly burst into the unprotected peritoneal cavity: pus contains enteric
bacteria
Signs and symptoms
- Diffuse abdominal tenderness, with voluntary and involuntary guarding over the entire abdomen
- Increased white blood cell, fever, tachycardia, and hypotension
¨ Diagnosis: plain X Ray or CT scans may reveal intraperitoneally free air
§ Colonic obstruction: due to scarring from repeated inflammation
Causes:
- Narrowing of the sigmoid because of the muscular hypertrophy of the bowel wall: sigmoidectomy may be the
only remedy if cancer cannot be ruled out
- Small bowel obstruction associated with the infectious and inflammatory aspect of diverticulitis: the small bowel
may become adherent to the phlegmon or abscess, with obstruction caused by the infectious process. NGT,
NBO, antibiotics, percutaneous drainage of the abscess.
§ Diverticular-associated colitis: Relatively unusual entity
Characterized by prolapse of the mucosa associated with diverticula and hyperplasia of the glands
¨ Clinical features: tenesmus, hematochezia, and diarrhea
¨ Endoscopic diagnosis: focal erythema, submucosal ecchymosis, erosions, and ulcers
¨ Pathologic findings: inflammation that could be consistent with ulcerative colitis or Crohn’s disease in areas of diverticular
disease
¨ It is a distinct clinical entity that presents with segmental colitis and has a variety of clinical and pathologic features.
DIAGNOSIS
diagnosis of diverticulitis and initiation of antibiotics can be made based on these typical findings
of history and physical examination. However, several radiologic findings can support it.
Possible physical examination findings:
§ There may be voluntary guarding, and tender mass in the left lower quadrant
suggestive of a phlegmon or absence
§ abdominal localized tenderness (focal peritonitis)
§ rebound tenderness and guarding (Diffuse peritonitis)
§ Rectal or vaginal examination- tender mass typical of a pelvic abscess
§ Abdominal rigidity implying of an abdominal wall distention in the presence of ileus
or obstruction secondary to the inflammatory process.
o Laboratory exams: Mild leucocytosis is a common laboratory finding
§ Acute diverticulitis: leukocytosis and high CRP
IMAGING
If the diagnosis is in doubt, 4 diagnostic tests can be considered: computed tomography
CT of the abdomen, magnetic resonance imaging, abdominal ultrasound, water soluble contrast enema. The selection among CT, MRI, and
ultrasound examination varies considerably among institutions
X-ray: AXR, upright CXR: look for signs of obstruction, perforation, air-fluid levels
Localized diverticulitis- ileus, thickened wall, SBO, partial colonic obstruction
¨ free air may be seen in 30% with perforation and generalized peritonitis
CT and MRI provide essentially the same information and advantages and reveal
The location of the infection
¨ Extend of the inflammatory process
¨ Presence and location of an Abscess: an Abscess detected by CT may often be drained by a percutaneous approach.
¨ Involvement of other organs, such as ureteral obstruction or a fistula to the bladder
CT scan of the abdomen and pelvic (test of choice): very useful for assessment of severity and prognosis; usually done with rectal
contrast
97% sensitive, 99% specific
¨ Increased soft tissue density within pericolic fat secondary to inflammation, diverticula secondary to inflammation, bowel
wall thickening, soft tissue mass (pericolic fluid, abscesses), fistula 10% of diverticulitis cannot be distinguished from
carcinoma
¨ In complicated diverticulitis; abdominal abscesses, increased colonic wall thickness, perforation, abdominal free air,
peritoneal fluid
US
§ Ultrasound: offers the possibility of percutaneous drainage of an Abscess.
Colonoscopy or barium enema flexible sigmoidoscopy- dangerous and are less used today (chemical peritonitis and ↑intraluminal
pressure that can worsen spread of infectious material) also, high risk of perforation.
Obstruction- colonoscopy to exclude carcinoma, if not feasibleà a retrograde contrast study or CT enterography.
¨ Colonoscopy should be performed in 4-6 weeks after resolution of symptoms to confirm the presence of diverticula and
to exclude cancer and colonic diseases (e.g. IBD)
¨ Sigmoidoscopy: air should not be insufflated through the endoscope because of the possibility that increased colonic
pressure could force more bacteria through the preparation into the peritoneal cavity.
CONTRAST ENEMA
an enema carries the risk of increasing the colonic pressure and causing father extravasation of feces through the
perforated diverticulum. The contrast should be water soluble. Water soluble contrast enemas do not carry the risk for barium fecal
peritonitis
DDX
mainly with ischemic colitis, ulcerative colitis
Treatment- The management of acute diverticulitis primarily depends on the severity of disease at presentation, and subsequently the approach to care
should be individualized
UNCOMPLICATED
conservative management. Uncomplicated diverticulitis is a disease not associated with free intraperitoneal perforation, fistula
formation, or obstruction.
§ Treat as outpatient with clear fluids only until improvement and antibiotics (e.g. ciprofloxacin and metronidazole) 7-10 d to cover
gram negative rods and anaerobes (e.g. B. fragilis)
§ Short-term diet modification as symptoms resolve. A first attack of uncomplicated diverticulitis that response to antibiotic therapy is
generally treated non operatively by the introduction of a high fiber diet. The chances of a second attack are less than 25%.
§ Hospitalize if severe presentation (local peritonitis), inability to tolerate oral intake, significant comorbidities, fail to improve
outpatient management
¨ Treat with NPO (null per os), IV fluids, IV antibiotics (e.g. IV ceftriaxone + metronidazole, ampicillin, gentamicin),
¨ opioid analgesia (avoid morphine use because it increases intracolonic pressure, meperidine decreases intraluminal
pressure and it is more appropriate).
§ Uncomplicated diverticulitis usually responds promptly with marked improvement in symptoms within 48 hours. After the symptoms
have subsided for at least three weeks, investigative studies should be conducted to establish the presence of diverticula and to
exclude cancer. These studies are colonoscopic examination, and barium enema can demonstrate the extent of the diverticular disease
, but a sigmoid cancer may be hidden.
§ If the patient suffers recurrent attacks of diverticulitis, surgical treatment should be considered
COMPLICATED
The recurrence in acute diverticulitis can be from 7% to 42%. Mostly occurs in the first year
and the risk is 3% for every following year. However only 5% of cases will develop complicated
diverticulitis in the next 10-30 years.
ABSCESSES TREATMENT
Large (≥4 cm13) pericolonicà with percutaneous drainage with CT or ultrasound
guidance + IV antibiotics usually results in a rapid clinical improvement.
Percutaneous drainage is better than laparotomy, which risks spreading the
contents of the Abscess throughout the peritoneal cavity
¨ Smaller abscessesà antibiotics and observation with interval imaging to ensure
complete resolution
¨ Elective surgery when the patient has completely recovered (6 weeks after). At
that time, it is possible to fashion an anastomosis avoiding colostomy. Remove all
the colon that is abnormally thickened: this avoids recurrent diverticulitis
§ Fistula: control the infection and reduce inflammation TREATMENT
Broad-spectrum antibiotics to ensure resolution of the inflammation
¨ Colonoscopy- exclude IBD and cancer as the cause of the fistula
¨ Elective resection of the involved colon and fistula tract +primary anastomosis.
Takedown the fistula and excise the sigmoid colon, then fashion an anastomosis
between the descending colon and rectum. Use of ureteral stents pre-op can
facilitate identifications of the ureters
GENERALIZED PERITONITIS TX
Excise the segment of colon containing the perforation. Eliminating the source of
infection by excising the perforated sigmoid colon, colostomy, irrigating the
peritoneal cavity and administrating IV antibiotics, along with nutritional support,
should result in resolution of the infection.
¨ It is not safe to restore intestinal continuity because and intestinal anastomosis
will not heal in an infectious environment.
¨ After complete recovery (at least 10 weeks) take down the colostomy and fashion the anastomosis.
¨ There have been recent reports of successful treatment of acute complicated diverticulitis by laparascopic lavage and IV
antibiotics, without resecting the diseased colon. However, resection of the perforated segment seems the safest approach
OBSTRUCTION
nasogastric tube for decompression
¨ antibioticsà treat the phlegmon that is pressing on the small bowel
BLEEDING DIVERTICULA
Only 15-25% of patients present with bleeding diverticula. Even 30-50% of hematochezia is caused by diverticula.
So even if the majority of diverticula don’t start with bleeding, most of the bleeding is part of the diverticula. The 75% of bleeding
cases are self-limiting. The risk of re-bleeding is 14-38%. It is interesting because it’s better to bleed than perforate. But there are a
few cases where it is really a heavy bleeding and you cannot control it. You need to do an angiography to see if you can block the
bleeding artery
§ Indications for surgery
Unstable patient with peritonitis
¨ Hinchey stage 3-4 (purulent/feculent peritonitis)15- usually accompanied by sepsis. What operation?
- Hartmann resection
- Esteriorization (Mickulicz procedure)
- Resection with primary anastomosis with temporary ileostomy
- Resection with primary anastomosis without ileostomy
After 1 attack if immunosuppressed. Mortality rates after surgery are higher
¨ Consider after >2 episodes, especially if the patient is young (<45y) and healthy patients. Recent trend is toward
conservative management of recurrent mild/moderate attacks. Patients less than 45 years old with one episode of
uncomplicated diverticulitis: some surgeons suggest elective sigmoidectomy following recovery (controversial).
Sigmoidectomy should be offered after two uncomplicated attacks to prevent a future complicated episode that would
require emergency operation or a colonostomy.
¨ Presence of complications: generalized peritonitis, perforation with free air, abscess, fistula, obstruction, hemorrhage,
inability to rule out colon cancer on endoscopy, or failure of medical management
For emergency or complex cases (i.e. generalized peritonitis
Hartmann procedure: The surgery described included the
resection of the disease sigmoid colon, construction of a
colonostomy using non inflamed descending colon, suturing
the divided end of the rectum closed
Traditionally, Hartmann procedure was done, with
colon resection + colostomy and rectal stump à
colostomy reversal in 3-6 months. You just take out
the diseased part of the colon and do a terminal
colostomy. However, Hartmann procedure is not
used anymore for diverticula because it is a benign
disease and the procedure is difficult
A retrospective study about Hartmann’s procedure
suggested that only 56% of patients operated with
Hartmann underwent later surgery for stoma
reversal. Other studies showed that the reversal of
Hartmann procedure alone has a morbidity rate of
20% and mortality rate of 1-6% because the part of
the rectum that remains is not easy to be
anastomosed with the other part after a Hartmann
procedure.
We don’t do Hartmann also because we do not want
to let the patient with a stoma for all of his life. We
just do a resection of the diseased part, we do the
anastomosis but an anastomosis with sepsis is not
safe at all. You have a high percentage of fistulas. So you do a colostomy but it is not used usually. We mainly
do a protection ileostomy before. So we drain the fecal portion for some months (one or two months) and then
when you are sure that the patient and the anastomosis are ok, you just close the stoma and the patient has a
normal life
- Emerging evidence suggests that for Hinchey stage III of acute
PROTECTION ILEOSTOMY :
laparoscopic
peritoneal lavage with drain placement near the affected colon, in addition to IV antibiotics (with NO
resections) along with nutritional support, offers lower mortality and morbidity compare to Hartmann
procedure. This procedure is gradually becoming standard practice
Emerging evidence suggests that for Hinchey stage III of acute complicated diverticulitis,
laparoscopic
peritoneal lavage with drain placement near the affected colon, in addition to IV antibiotics (with NO
resections) along with nutritional support, offers lower mortality and morbidity compare to Hartmann
procedure. This procedure is gradually becoming standard practice
Elective cases or minimal contamination of the abdominal cavity: consider
colon resection + primary anastomosis
(‘elective sigmoidectomy’)
- anastomosis should be made to the upper rectum to minimize the risk of recurrent disease
- laparoscopic/open approach have similar morbidity and mortality
- benefits of laparoscopy: less pain, quicker recovery of bowel function, and shorter hospital stays (2-3 days
shorter than patients with an open approach)
PROGNOSIS
mortality rates: 6% for purulent peritonitis, 35% for fecal peritonitis
2. recurrence rates: 13-30% after first attack, 30-50% after second attack
ANTIBIOTIC TREATMENT
Third generation cephalosporin or ciprofloxacin and metrodinazole targeting gram-negative rods and anaerobic bacteria
For enterococci–> Ampicillin
Or single-agent therapy with 3rd generation penicillin
*IV piperacillin
*IV oral penicillin/clavulanic
7-10 days
