Diverticular disease of the colon.

Diverticulosis:
Definition:
-Diverticulosis is a condition in which diverticula can be found within the
colon, especially the sigmoid; diverticula are actually false diverticula in
that only the mucosa and submucosa herniate through the bowel
musculature; true diverticula involve all layers of the bowel and are rare in
the colon.
- In asia they are more common on the right side of the colon
- It is due to weakness in the bowel wall which develop at points where
nutrients blood vessels enter between antimesenteric and mesenteric taenia;
increased intraluminal pressures then cause herniation through these areas.
- People with low fiber diets, chronic constipation, obesity and a positive
family history are at risk of diverticulosis. The incidence increases with age.
There is no gender difference.
- signs and symptoms include:

Bleeding
Massive diverticulitis
asymptomatic. (very common)

Diagnostic approach:

Bleeding: without signs of inflammation: colonoscopy

Pain and signs of inflammation: Abdominal/pelvic CT scan

- It is safe to get a colonoscopy or barium enema/ sigmoidoscopy 6 weeks

after inflammation resolves due to the risk of perforation. It is done to rule
out colon cancer.
Treatment:
-High fiber diet is recommended.
Surgery:
- Recommendations:

Complications of diverticulitis (fistula, obstruction, stricture)

Recurrent episodes
hemorrhage
Suspected carcinoma
prolonged symptoms
Abscess not drainable by percutaneous approach.

Diverticulitis:
Definition:
- Inflammation/Infection or perforation of a diverticulum.
- Pathophysiology: Obstruction of a diverticulum by a fecalith leading to
inflammation and microperforation.
History

Ask about pain (LLQ pain (cramping or steady)) --> SOCRATES

change in bowel habits (diarrhea or constipation)
Blood in the stool (red, maroon, Black)
fever/chills (frequency, type) Yes/ Yes
Anorexia/ weight change? Yes (ileus also)
LLQ mass
Nausea/vomiting Yes/Yes
Pain upon urination (Dysuria)
Change in urine Dysuria
Distended abdomen?
What kind of diet?
Previous hospitalization
Past medical / Family Hx / Medication/ past surgeries
Alcohol / smoking/ profession. / allergies

- In diverticulosis ask same questions but don't expect systemic findings

because no infections.
- BLEEDING ONLY IN DIVERTICULOSIS. ( LOWER GI BLEEDING)
Physical exam:

Check vital signs to see severity of the disease (tachycardia, fever,

hypotensive--> signs of sepsis)
Abdominal exam
DRE

- With acute diverticulitis we expect to find:

Low grade fever

Abdominal distention or asymmetry due to an inflammatory process
tenderness localized in LLQ
Rebound: percussion, palpation
Rule out colon cancer.

Hinchey classification:
The management of acute diverticulitis is largely dictated by the stage of the
disease at presentation:
Stage 0 : mild clinical diverticulitis --> treated conservatively with bowel rest
and antibiotics for anaerobes and gram negative rods. If young, stable and
no co morbidities: do it orally, if older with co morbidities: IV hospitalization.
Stage 1a: Inflammation confined to the pericolic region --> above treatment
Stage 1b: Presence of pericolic abscess or phlegmon
Stage 2: Pelvic, retroperitoneal, distant intraperitoneal abscess/ phlegmon
--> stage 1b and 2 need percutaneous drainage and antibiotics
Stage 3: complicated diverticulitis --> presence of diffuse peritonitis and no
communication between bowel and peritoneal cavity.
stage 4: feculent peritonitis and communication between bowel and
peritoneal cavity --> stage 3 and 4 need emergent surgery.

Laboratory studies:

CBC with differential: Increase WBC, hemoglobin and hematocrit for

dehydration and anemia
Electrolytes and renal studies: for dehydration
Urinalysis: for symptoms of UTI to check for colovesicular fistula
PT/ PTT, Type and screen studies
Beta HCG to rule out pregnancy in women prior to surgery.

Imaging:

Colonoscopy: Do not do colonoscopy in patient who is acutely ill. We

do it to examine the colon and check for 1) diverticulitis and 2) any
polyps or colon cancer.
Abdominal Xray
1. Upright chest Xray: allow us to see the diaphragm and help us
detect presence of any free air in the abdomen.
2. Flat abdominal Xray: Show us presence of free air which implies
presence of perforation or if there is an ileus or obstruction.
3. Upright abdominal Xray
Double contrast barium enema : not for acute attack, used as a road
map before surgery
CT scan of abdomen and pelvis (best test): in acute diverticulitis we
see
1. Fat stranding
2. bowel thickening
3. extraluminal air
4. Swollen, edematous bowel wall;
5. In complicated diverticulitis: fistulas, Abscess, phlegmon.

Complications:
Abscess, diffuse peritonitis, fistula (most common colovesicular),
obstruction, perforation, stricture.
Work up:

Initial treatment:
1. IV fluids
2. NPO
3. Broad spectrum antibiotics with anaerobic coverage
4. NG suction
Treatment of diverticular abscess: percutaneous drainage, if not
possible --> surgery
Surgery warranted if:
1. Obstruction
2. fistula
3. free perforation
4. abscess not amenable to percutaneous drainage
5. sepsis
6. deterioration with initial treatment
Elective resection:
1. Two episodes of diverticulitis: should be considered after the first
episode in a young, diabetic, or immunosupressed patient.

Surgery:
- Elective surgery: one stage operation --> resection of involved segment
and primary anastomosis ( with preop bowel preparation)
- Surgery for an acute case of diverticulitis with a complication: Hartmann's
procedure with subsequent reanastomosis of colon usually after 2-3 post op
months
Post operative care:

Check for bowel movement

1. Passage of gas and bowel movement
2. Nausea/ vomiting
NGT can be removed unless high output is recorded.
Advance diet if patient is tolerating it, not having nausea and
abdominal distention.
Pain control
Encourage ambulation and use of incentive spirometer
Monitor wound infection, intra abdominal abscess