شاهین زارع
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Transcript of شاهین زارع
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زارع شاهین
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Diverticulitis
Diverticulitis = inflammation of diverticuli
Most common complication of diverticulosis
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Pathophysiology of Diverticulitis increased intraluminal pressure
inflammation
Usually inflammation is mild
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Diagnosis of Diverticulitis
Previous of episodes of similar pain
Associated symptoms Nausea/vomiting 20-62% Constipation 50% Diarrhea 25-35% Urinary symptoms (dysuria, urgency,
frequency) 10-15%
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Diagnosis of Diverticulitis
Right sided diverticulitis tends to cause RLQ abdominal pain; can be difficult to distinguish from appendicitis
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Diagnosis of Diverticulitis
Physical examination Low grade fever LLQ abdominal tenderness
Usually moderate with no peritoneal signs Painful pseudo-mass in 20% of cases Rebound tenderness suggests free
perforation and peritonitis
Labs : Mild leukocytosis 45% of patients will have a normal WBC
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Diagnosis of Diverticulitis
Clinically, diagnosis can be made with typical history and examination
Radiographic confirmation is often performed Rules out other causes of an acute
abdomen Determines severity of the diverticulitis
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Treatment of Diverticulitis
Complicated diverticulitis = Presence of macroperforation, obstruction, abscess, or fistula
Uncomplicated diverticulitis = Absence of the above complications
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Uncomplicated diverticulitis
Bowel rest or restriction Clear liquids or NPO for 2-3 days Then advance diet
Antibiotics for 7-10 days
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Uncomplicated diverticulitis
Antibiotics Coverage of fecal flora
Gram negative rods, anaerobes
Common regimensCipro + Flagyl x 10 daysAugmentin or Unsayn x 10 days
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Uncomplicated diverticulitis
Monitoring clinical course Pain should gradually improve several
days (decrescendo) Normalization of temperature Tolerance of po intake
After resolution of attack high fiber diet with supplemental fiber
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Uncomplicated diverticulitis
Follow-up: Colonoscopy in 4-6 weeks
Flexible sigmoidoscopy and BE reasonable alternative
Purpose Exclude neoplasm
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Prognosis after resolution
Second attack Risk of recurrent attacks is high (>50%)
Some studies suggest a higher rate (60%) of complications (abscess, fistulas, etc) in a second attack and a higher mortality rate (2x compared to initial attack)
After a second attack elective surgery
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Prognosis after resolution
Some argue elective surgery should be considered after a first attack in
Young patients under 40-50 years of age Immunosuppressed
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Complicated Diverticulitis
Peritonitis Antibiotics
Ampicillin + Gentamycin + Metronidazole Imipenem/cilastin Zosyn
Emergency exploration Mortality 6% purulent peritonitis and 35%
fecal peritonitis
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Complicated Diverticulitis: Abscess Occurs in 16% of patients with acute
diverticulitis
Percutaneous drainage followed by single stage surgery in 60-80% of patients
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Complicated Diverticulitis: Abscess CT guided drain
Leave in until drain output less than 10 mL in 24 hours
May take up to 30 days
Catheter sinograms helpful to show persistent communication between abcess and bowel
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Complicated Diverticulitis: Abscess Small abscesses too small to drain
percutaneously (< 1cm) can be treated with antibiotics alone
These pts behave like uncomplicated diverticulitis and may not require surgery
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Complicated Diverticulitis: Fistulas
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Complicated Diverticulitis: Fistulas Occurs in up to 80% of cases requiring
surgery Major types
Colovesical fistula 65% Colovaginal 25% Coloenteric, colouterine 10%
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Complicated Diverticulitis: Fistulas - Symptoms Passage of gas and stool from the
affected organ
Colovesical fistula: pneumaturia, dysuria, fecaluria
50% of patients can have diarrhea and passage of urine per rectum
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Complicated Diverticulitis: Fistulas Diagnosis
CT: thickened bladder with associated colonic diverticuli adjacent and air in the bladder
BE: direct visualization of fistula track only occurs in 20-26% of cases
Flexible sigmoidoscopy is low yield (0-3%) Some argue cystoscopy helpful
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Complicated Diverticulitis: Treatment of Fistulas Surgery
Resection of affected colon (origin of the fistula)
Fistula tract can be “pinched off” most of the time
Suture closure for larger defects Foley left in 7-10 days
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Any question?