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Diverticulitis

Arnelis
7 February 2018
Div Gastroenterohepatology IPD FKUA
Diverticular Disease
• Diverticulosis
• Diverticulitis
Diverticulosis

• Common disease with age


• Cause unknown
• Potential causes:
– Constipation
– Pressure caused by
moving dry, hard
bowel movements
• Diverticula
– pouch-like projections

http://digestive.niddk.nih.gov
Diverticulitis
• Inflammation of the diverticula
• Material caught in pocket causes
inflammation, infection
and bleeding.
Signs and Symptoms
• Diverticulosis
– Most people have no pain or symptoms
– Diarrhea
– Constipation
– Flatulence
– Heartburn
What causes Diverticular Disease?
• Lack of fiber in diet
– weak areas form pouches
• Lack of exercise
Diverticulitis
Pathophysiology

• Diverticula
– Acquired or congenital
– Can affect small or large intestine
– May be related to an increase in intramural
pressure
– Occurs in the weakest areas of the colonic wall
• Adjacent to the vasa recta
• Mesenteric side of the colon

Joffe, S, Kachulis, A., Emedicine, Online Version, 2005, Colon, diverticulitis, www.emedicine.com
• DiverticulaDiverticulitis
Definition
– Etiology
• Outpouchings
– Occur in areas weak and under stress
– Prolapse of mucosa and submucosa may
occur.
• Location
– Arteries penetrate the muscularis to
reach the submucosa and mucosa.
– Diverticula form through entire colon
» Left colon
» Sigmoid (most common)
http://health-pictures.com/diverticulitis-picture.htm » Right sided (uncommon)

Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
• DiverticulaDiverticulitis
EPIDEMIOLOGY
Definition
• Overall prevalence - 12% to 49% •
Increases with age
< 10% in those younger than 40 years >
50% to 66% of patients 80 years

• As common in men and women


http://health-
pictures.com/diverticulitis- • Men - higher incidence of diverticular
picture.htm
bleeding
• Women - more episodes of obstruction or
stricture
Disease of Western civilization • Extraordinarily rare in
rural Africa and Asia • Highest prevalence rates - united
States, Europe, and Australia • Increase with
urbanization
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Location
• Location
Arteries penetrate the muscularis to reach the
submucosa and mucosa.

Diverticula form through entire colon


Left colon
Sigmoid (most common)
Right sided (uncommon)
Diagnosis
o
• Plain Films -abnormal in 30% to 50%
• Contrast Enema Examinations - only watersoluble
contrast enemas, such as Gastrografin, should be
used
• A gentle, single-contrast study should be
performed and terminated once findings of
diverticulitis are discovered,
• Findings -- extravasated contrast material with or
without the outlining of an abscess cavity, an
intramural sinus tract, or a fistula
CT Scan
o
Computed Tomography
• Diagnostic procedure of choice for acute diverticulitis
• Because diverticulitis is mainly an extraluminal disease
• CT criteria for diverticulitis- presence of diverticula - with
pericolic infiltration of fatty tissue (often appearing as fat
stranding), - thickening of the colon wall - and formation of
abscesses
Endoscopy
o
• Suspected acute diverticulitis - endoscopy generally is avoided
(risk of perforation, either from the instrument itself or from
air insufflation)
• Once the acute phase has passed (one to three months later),
a colonoscopy should be electively performed to exclude
competing diagnoses, particularly neoplasia
o
Treatment -Uncomplicated
diverticulitis
Out patient
o
• Mild symptoms
• No peritoneal signs
• The ability to take oral fluids • Supportive home network
• These patients should be treated with a clear liquid diet and
antibiotics.
• Mixed aerobic and anaerobic organisms
( Escherichia coli, Streptococcus species, and Bacteroides
fragilis )
Hospitalization
o
• Elderly
• Immunosuppressed
• Severe comorbidities
• High fever / significant leukocytosis
• Bowel rest /Intravenous fluid
• Broad-spectrum intravenous antibiotics should be started
Hospitalization
o
•If improvement continues, patients may be discharged, but
they should complete a seven- to 10-day course of oral
antibiotics.
• Failure to improve with conservative medical therapy warrants
a diligent search for complications, consideration of
alternative diagnoses, and surgical consultation
Complicated
o
• Abscess • Small pericolic abscesses (Hinchey stage I)
• Noninterventional management- with broadspectrum
antibiotics and bowel rest • Continued of abscesses should be
considered only in stable patients who demonstrate
unequivocal improvements in pain, fever, tenderness, and
leukocytosis over the first few days of therapy.
• Percutaneous catheter drainage
• Single operation (resection with primary anastomosis) have
become the preferred surgical approaches • Two-stage
management - Hartmann procedure