DIVERTICULITIS

Question 1

Diverticulum:

Answer 1

abnormal sac-like protrusion from the wall of a
hollow organ

Question 2

Diverticulosis

Answer 2

presence of multiple diverticula

Question 3

Diverticulitis

Answer 3

inflammation of diverticula

Question 4

True (congenital) diverticuli:

Answer 4

contain all layers of colonic wall,
often right-sided

Question 5

False (acquired) diverticuli:

Answer 5

contain mucosa and submucosa,
often left-sided

Question 6

Colonic diverticula

Answer 6

protrusions of mucosa through the muscular
layer of the intestine. Because these mucosal herniations are
devoid of the normal muscular layers, they are pseudodiverticula

Question 7

Diverticulosis

Answer 7

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

Question 8

Epidemiology

Answer 8

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

Question 9

Pathogenesis

Answer 9

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.

Question 10

Where?

Answer 10

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.

Question 11

RFs

Answer 11

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)

Question 12

CLINICS

Answer 12

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.

Question 13

TREATMENT

Answer 13

Uncomplicated diverticulosis: high fibre, education
o Diverticular bleed
§ initially workup and treat as any LGIB
§ if hemorrhage does not stop, resect involved region

Question 14

DIVERTICULITIS

Answer 14

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.

Question 15

Where?

Answer 15

The sigmoid colon has this highest incidence of diverticula and it is the most frequent site for
involvement with diverticulitis.

Question 16

EPIDEMIOLOGY

Answer 16

95% left-sided in patients of Western countries,
o 75% right-sided in Asian populations

Question 17

PATHOGENESIS

Answer 17

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)

Question 18

Diverticulitis has a broad spectrum of severity (single episode, repeated episodes or fulminant
complicated disease characterized by life-threatening sepsis).

Answer 18

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.

Question 19

CLINICS

Answer 19

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

Question 20

The most common physical findings are:

Answer 20

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)

Question 21

o The physical findings are dependent on

Answer 21

The site of perforation
§ Amount of contamination
§ Presence or absence of secondary infection of adjacent organs

Question 22

o Complications (25% of cases)

Abscess: palpable tender abdominal mass.

Answer 22

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

Question 23

Fistula: colovesical (most common), coloenteric, colovaginal, colocutaneous

Answer 23

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.

Question 24

Generalized peritonitis due to perforation

Answer 24

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

Question 25

§ Colonic obstruction: due to scarring from repeated inflammation

Answer 25

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.

Question 26

§ Diverticular-associated colitis: Relatively unusual entity

Answer 26

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.

Question 27

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.

Answer 27

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

Question 28

IMAGING

Answer 28

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

Question 29

X-ray: AXR, upright CXR: look for signs of obstruction, perforation, air-fluid levels

Answer 29

Localized diverticulitis- ileus, thickened wall, SBO, partial colonic obstruction ¨ free air may be seen in 30% with perforation and generalized peritonitis

Question 30

CT and MRI provide essentially the same information and advantages and reveal

Answer 30

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

Question 31

CT scan of the abdomen and pelvic (test of choice): very useful for assessment of severity and prognosis; usually done with rectal contrast

Answer 31

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

Question 32

US

Answer 32

§ Ultrasound: offers the possibility of percutaneous drainage of an Abscess.

Question 33

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.

Answer 33

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.

Question 34

CONTRAST ENEMA

Answer 34

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

Question 35

DDX

Answer 35

mainly with ischemic colitis, ulcerative colitis

Question 36

Treatment- The management of acute diverticulitis primarily depends on the severity of disease at presentation, and subsequently the approach to care should be individualized

Answer 36

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

Question 37

COMPLICATED

Answer 37

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.

Question 38

ABSCESSES TREATMENT

Answer 38

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

Question 39

§ Fistula: control the infection and reduce inflammation TREATMENT

Answer 39

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

Question 40

GENERALIZED PERITONITIS TX

Answer 40

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

Question 41

OBSTRUCTION

Answer 41

nasogastric tube for decompression ¨ antibioticsà treat the phlegmon that is pressing on the small bowel

Question 42

BLEEDING DIVERTICULA

Answer 42

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

Question 43

§ Indications for surgery

Answer 43

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

Question 44

For emergency or complex cases (i.e. generalized peritonitis

Answer 44

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

Question 45

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

Answer 45

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.

Question 46

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

Answer 46

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

Question 47

Emerging evidence suggests that for Hinchey stage III of acute complicated diverticulitis,

Answer 47

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

Question 48

Elective cases or minimal contamination of the abdominal cavity: consider

Answer 48

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)

Question 49

PROGNOSIS

Answer 49

mortality rates: 6% for purulent peritonitis, 35% for fecal peritonitis 2. recurrence rates: 13-30% after first attack, 30-50% after second attack

Question 50

ANTIBIOTIC TREATMENT

Answer 50

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