Diverticular diseases

of the bowel

Dr.Abdelkhalig Elhilu
Assistant professor of surgery

Anatomy
Colonic diverticulum

A colonic diverticulum is an acquired

herniation of the mucosa (usually in the
sigmoid) protruding through the circular muscle
layer.
 Believed to be due to reduced fiber in diet.
 It can cause lower GI bleeding or become
inflamed leading to diverticulitis

Colonic diverticulitis:

Acute :
 Persistent left iliac fossa pain with or without
peritonitis.
 Systemic symptoms – fever , malaise.
 Diarrhea or constipation.
 Tender LIF.
 Palpable tender thickened sigmoid.
 Urinary symptoms (UTI, pnematuria) if
bladder is involved
Complications:

 Perforation and peritonitis.

 Pericolic abscess.
 Fistula formation (colo-vesical, colo-
vaginal,colo-enteric, colo-cutaneous).
 Intestinal obstruction (small & large bowel).
 Haemorrhage.

Hinchey classification of complicated diverticulitis

Grade I Mesenteric or pricolic abscess

Grade II Pelvic abscess
Grade III Purulent peritonitis
Grade IV Faecal peritonitis
Chronic mild cases :
 Distension, flatulence, feeling of heaviness in
lower abdomen

Bleeding colonic diverticulae

 Usually painless and profuse

 Bright red with clots if coming from sigmoid
and dark colour if coming from right colon
 Usually responds to conservative
management
 Occasionally requires resection
Investigations:

 Radiology – CT scan (acute), barium enema

(recovered pts), gastrograffin enema
(obstruction).
 Sigmoidoscopy ( recovered pts).
 Colonoscopy

Barium enema
Double contrast barium enema

Colonoscopy
CT scan (pericolic abscess)

Management

 Fluid resuscitation (if there is peritonitis), nil by

mouth, IV antibiotics
 Abscesses can be drained percutaneously
 Perforation – laparotomy and Hartmann’s procedure.
 Obstruction – Hartmann’s procedure.
 Fistulae – resection of diseased bowel and closure
of the fistula.
 Resolved cases – resection and anastomosis.
Hartmann’s procedure

Small bowel diverticulae

1. Meckel’s diverticulum:
 Congenital in origin
 Persistent remnant of the vitellointestinal duct
 Present in 2% of the population
 Found 60 cm from ileocecal valve in the anti
mesentric border of the ileum
 Contains heterotopic epithelium in 20% of cases
(gastric, pancreatic or colonic)
 Majority of cases are asymptomatic
Complications

I. Hemorrhage : painless dark rectal bleeding

or melena ( diagnosis by radioisotpe scan if
other causes are excluded)
II. Meckel’s diverticulitis : mimics appendicitis
III. Intussusception : (ileoileal or ileocolic)
IV. Chronic ulceration : (periumblical pain)
V. Intestinal obstruction
VI. Perforation

Non complicated Meckel’s Gangrenous Meckel’s

Quiz

What to do if Meckel’s is accidentally found?

Jejunal diverticulae

 Arise from mesenteric border as they are acquired

 Usually multiple
 They are rare and commonly asymptomatic
 Can cause; malabsorption, bleeding, inflammation or
perforation