Diverticular Disease

Dr. Matt W. Johnson

Introduction & Overview

• Pathology• Physiology• Location• Complications

– Bleeding– Obstruction– Fistula– Acute Diverticulitis

• Management of Acute Diverticulitis

Pathology

• Congenital• Acquired

– association with Western diets high in refined carbohydrates and low in dietary fibre1

– Deficiency of vegetable fibre in diet2

– Disordered motility– Hyperelastosis may lead to structure change– Collagen abnormalities– Age

• Diverticular disease occurs in over 25% of the population, increasing with age3

1 Ferzoco et al Lancet 1998; 2 Simpson et al Br J Surg 2002; 3 Janes et al BJS 2005

Physiology

• La Place effects• High intra-luminal pressure• Resultant characteristic protrusion mucosa• Worst at terminal arterial branches • Rectal sparing

– ?due to complete layer of longitudinal muscle and large diameter

Physiology and Anatomy

•Terminal arterial branches

•Penetrate circular muscle

•Often lie adjacent to taenia

Location

• Classically Sigmoid• In Orient often right-sided• Rectal Sparing

• Can occur anywhere(but considered separately)e.g. Small bowel –see later

Right vs. Left

Complications

• Obstruction• Bleeding• Inflammation “itis”

– Fistula – Sepsis– Perforation

• May co-exist with IBD

Specimen showing blood in diverticulae

Obstruction in Diverticular Disease

• Progressive distension

• Single contrast enema will delineate this

• Often present like cancer

• Diagnosis – often only at operation (opened specimen) or – on histology

Bleeding in Diverticular Disease

• Rarely exsanguinating• Often requires repeat transfusion• Consider mesenteric angiography if available

– Embolisation (risk of ischaemia and infarction)– Allows targeted resection

• Operative intervention uncommon– On table colonoscopy– Exclusion

Re-Bleeding Rates

Re-bleeding rateYear Percentage

1 9

2 10

3 19

4 25

1 Longstreth Am J Gastro 1997

Other Causes Of Colonic Bleeding

• Exclude–IBD–Neoplasm–Angiodysplasia–Ischaemic colitis–Radiation proctitis– Varices

Fistula

• Abnormal connection• Commonest communications are

– Colovesical– Colovaginal (esp if prev TAH)

• Colovesical Symptoms– Pneumaturia– Recurrent infections– Faecalent urine or particulates

• Diagnosis of site/communication vs pathology– CD/CRC/TCC

Acute Diverticulitis

• Abscess– Peridiverticular– Mesenteric– Pericolic

• Perforation– Concealed– Free

• Peritonitis (gangrenous sigmoididits)– Purulent or serous or faecal– Local or generalised or pelvic

1 Killingback Surg Clin North Am 1983

Emergency Presentation

• Symptoms– Generally unwell– Pain localising to left iliac fossa*– Abdominal distension– Altered bowel habit e.g. diarrhoea– Nausea/Fever

• Signs– LIF tenderness– *Beware RIF pain-in right sided diverticulitis and

where sigmoid crosses midline– Systemic signs (T/HR/BP/WCC)– May be palpable on pR at anterior rectal wall

Management

• Resuscitation• Analgesia• Bloods• ECG/Catheter/Urine• Rectal examination (+/-sigmoidoscopy)• CXR• AXR• USS• CT Scan• Operative intervention

CXR

AXR

Diverticular disease

CT Scan

Perforated diverticulitis of the sigmoid colon-CT

Diverticulitis with pericolic abscess

Operative Picture

Perforation

Operative considerations

• Serial assessment and clinical judgement – (even if Radiological perforation)

• Operative indications– generalized peritonitis– uncontrolled sepsis,– visceral perforation– acute clinical deterioration

• At operation– Resection better than no resection1

– Hartmann’s vs anastomosis

1 Krukowski & Matheson Br J Surg 1984

Anastomosis

• Is there any role for primary anastomosis in the inflamed bowel?

• Consider if fully resuscitated and colorectal Surgeon• Retrograde gun/washout kit• Schilling et al. 2001 Diseases of the Colon and Rectum

– diverticulitis with peritonitis – 13 patients one stage– 42 Hartmann’s procedure– 7% mortality in both groups

• Similar complication rates– Not a study of bowel obstruction

Elective Presentation

• Via outpatients• Often milder version of emergency

presentation• Incidental radiological finding

– AXR– Contrast study e.g. Barium Enema– CT scan

• Rarely if insiduous, an abscess may be found on Barium Enema as an outpatient

Elective resection for Diverticultis

• After recovering from an episode of diverticulitis the individual risk of an urgent Hartmann’s is 1 in 2000 patient-years of follow-up.

• Surgery for diverticular disease has a high complication rate

• 25% of patients have ongoing symptoms after bowel resection (IBS/IBD)

• No evidence to support the idea that elective surgery should follow two attacks of diverticulitis.

• Further prospective trials are required.1 Janes et al BJS 2005

Duodenal and Jejunal Diverticulosis

• Separate from colonic diverticulosis. • Most occur in the jejunum and occasionally duodenum. • Jejunal diverticula are acquired protrusions of the

mucosal lining through the muscular wall of the bowel. • Encourages particular bacterial overgrowth. • A combination of alteration of the intraluminal contents

by these bacteria may result in malabsorption – Calcium– Iron– Vitamins D or B12.

• Patients may present with anaemia and occasionally osteomalacia.

Proximal Jejunal Diverticulitis

Incidental Jejunal Diverticular

Proximal Jejunal diverticulitis with perforation

Questions

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