Diverticulitis

Diverticulitis
Diverticulitis
Outline
• Definition
• Pathophysiology
• Epidemiology
• Clinical presentation
• Differential
• Imaging
• Laboratory
• Treatment
• Reasons for surgery
Diverticulitis
Definition
• Diverticula – 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
http://health-pictures.com/diverticulitis-picture.htm
» Left colon
» Sigmoid (most common)
» Right sided (uncommon)
Saunders, W., B., Wilcox, M., 2004, Elsevier imprint, Cecil’s Textbook of Medicine, Chapter 143, Online version, Diverticulitis
Diverticulitis
Definition
• Diverticulitis – Fecalith becomes impacted

in a diverticulum
– Erosion through the serosa
• Perforation
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
Diverticulitis
Pathophysiology
– Theories
• Deficiency in dietary fiber
– Western diet
– Decreased fecal bulk
– Narrowing of the colon
– Small fecal mass
» Increased intraluminal pressure needed to move
material
• Loss of tensile strength
• Decrease in elasticity
– Proof?
• High fiber diet appears to decrease incidence
Brunicardi, C., F., Schwartz principles of surgery, pp 1082-1084, 8th edition, 1999
Diverticulitis
Pathophysiology
• Diverticula
– False diverticula (pulsion)
• Herniation through colonic wall
– Mucosa
– Muscularis
• Occur between tenia coli
– Points of weakness
• High intraluminal pressure
• Bleeding is self limiting
– True diverticula
• Rare and usuall congenital
• Comprise all layers of bowel wall
Diverticulitis
Pathophysiology
• Diverticulitis
– Inflammation in and around a diverticulum
– Stagnation of nonsterile inspissated fecal material (fecalith)
• May compromise the blood supply
• Cusing inflammatory erosion of the mucosal lining
• Perforation
– Intramural abscess
– Fibrinous exudate
– Abscess formation
– Local adhesions
– Peritonitis
– Sealed-off abscesses
– Contained sinus tracts
– Fistulas
Diverticulitis
Epidemiology
• Frequency in US
– Diverticular disease
• 5% of population at age 40
• 33-50% of population older than 50
• 80% of population older than 80
– Diverticulitis
• 10-20% of patients with diverticular disease
• Frequency internationaly
• Diverticulosis occurs in 0.2% of population
Diverticulitis
Epidemiology
• Mortality and Morbidity

– 20% require surgical therapy
– Mortality rate of 7.7% (if peritonitis is present)
• Race
– Asians predisposed to right sided diverticulitis
• Sex
– No relationship
• Age
– Disease increases with age
Diverticulitis
Clinical Manifestations
• Symptoms
– Pain
• Typically located in left lower quadrant
• Subacute and constant pain
• Right sided diverticulitis can occur (congenital?)
– Fever
• Almost invariably present
• High-grade fever and sepsis
– If perforation is not contained or
– When the peritonitis is generalized
– Constipation or loose stools may be reported
– Rectal bleeding is unusual.
Diverticulitis
Clinical Manifestations
• Fistulas occur in 5% of patients w/

complicated diverticulitis
– Colovesical
– Colovaginal
– Coloenteric
Diverticulitis
Differential Diagnosis
• Lower abdominal pain, fever, Acute severe abdominal pain
– Perforation of an abdominal viscus
and bloody diarrhea • Peptic ulcer
– Bacterial colitis (Shigella, •
•
Small bowel obstruction
Choledocholithiasis
Salmonella, Campylobacter) • Nephrolithiasis
• Rupture and dissection of an abdominal aortic
– Ischemic colitis aneurysm
–
– Inflammatory bowel disease Subacute onset of pain
• Intestinal ischemia
• Cholecystitis
• Pancreatitis
• Generalized peritonitis •
•
Diverticulitis
Crohn's disease
– Acute abdomen • Appendicitis
– Pain of a constant nature
• Cholecystitis
• Pancreatitis
• Gynecologic disorders • Intestinal ischemia
• Inflammatory disorders
– May be localized to the left – Colicky pain occurs
lower quadrant (LLQ) • Nephrolithiasis
• Intestinal obstruction
– Radiation of pain
• Pancreatitis
• Peptic ulcer disease
• Biliary tract disease
– Shoulder pain
• Diaphragmatic irritation
– Significant vomiting is seen with pancreatitis
or obstruction of the stomach or small bowel.
Diverticulitis
Laboratory
• Leukocytosis
– Common, nonspecific
• Urinalysis
– Protein or rare white blood cells may be found
• Nonspecific
• Fecal leukocytes
• Should be sought if diarrhea is present
Diverticulitis
Imaging
• Abdominal radiographs
– May indicate
• A displaced colon
• Extraluminal gas
• Colonic mucosal abnormalities
– More helpful in excluding other potential
causes of left lower quadrant pain.
Diverticulitis
Imaging
• Abdominal CT
– Test of choice
– May demonstrate
• Bowel wall thickening
• Abscess formation
• Diverticula
• Diagnostic barium enema
– Safe when carefully performed
– Findings include
• Spiculation of the mucosa
• Spasm
• Frank perforation
• Abscess
– Findings specific for diverticulitis, but may be hard to distinguish from carcinoma
• CT and barium enema are complementary

– Neither is 100% sensitive or specific.
Diverticulitis
Imaging
• Computed
tomographic scan
– Marked thickening of
• Distal end of the
descending colon
– Inflammatory changes
(straight arrow)
– Extraluminal gas
(curved arrow)
Diverticulitis
Imaging
• Barium Enema
– Colon with sinus
formation
– Shows multiple
diverticula
– Communicating sinus
is clearly seen (arrow).
Diverticulitis
Imaging
• Endoscopic examination
– Contraindicated with diverticulitis
– Theoretical potential to exacerbate perforation
– Can detect diverticulosis before or between
attacks
• Sigmoidoscopy
– Appropriate when
• Carcinoma or
• Inflammatory bowel disease is highly suspected
Diverticulitis
Imaging
• Colonoscope
– Wide-mouthed
openings to diverticula
– Colonoscopy may be
difficult and hazardous
when diverticula are
large enough to admit
the tip of the scope.
Beers, M., 2005, Merck Manual of Medical Information, Online version, http://www.merck.com/mmhe/sec09/ch128/ch128c.html
Diverticulitis
Treatment
• Mild diverticulitis
– Initially (symptoms usually disappear rapidly)
• Rest
• A liquid diet
• Oral antibiotics
– After a few days
• Soft, low-fiber diet and take a daily psyllium (i.e. metamucil) seed preparation.
– After 1 month
• A high-fiber diet can be started
• Severe symptoms— (perforation, peritonitis)
– Admitted to hospital
– Intravenous fluids and antibiotics
– Bedrest
– Nothing by mouth until the symptoms subside
About 20% of people who have diverticulitis require surgery because the condition
does not improve.
Diverticulitis
Treatment
• Inpatient
– Broad-spectrum antibiotics
• Third-generation cephalosporin
– Ceftriaxone 1.5mg intravenously daily
• Anaerobic coverage
– Metronidazole 250mg intravenously three times daily
– At discharge
• Oral antibiotics to complete 14 day course
• Ciprofloxacin and Metronidazole)
• Outpatient (mild disease)
– Oral antibiotics (14 days)
• Ciprofloxacin (500mg twice daily)
• Metronidazole (250mg three times daily) for 14 days
– Bowel rest
Diverticulitis
Treatment
• Colon carcinoma may mimic diverticulitis

– Colonoscopy or sigmoidoscopy is
recommended 4-6 weeks after recovery when
surgery is not performed
Diverticulitis
Treatment
• Early surgical consultation is important

– Especially in the presence of significant pain
or
– An acute abdomen
• Percutaneous catheter drainage

– If large abcess is present
• Temporary
Diverticulitis
Treatment
• Some reasons for surgery

– Colonic stricture
– Bleeding
– Fistula formation to
• The small bowel
• Colon
• Bladder
• Vagina
Surgcial resection
– Warranted in reoccurrences (1/3 of all patients)
– Sigmoid colectomy with anastamosis
Diverticulitis
Treatment
• Hinchey staging • Percutaneous

– Stage I drainage?
• Colonic inflammation • If not….
• Pericolic abcess
– Sigmoid colectomy w/
– Stage II primary anastamosis
• Colonic inflammation • Stage I or II
• Retroperitoneal or
– Sigmoid colectomy w/
• Pelvic abcess
hartman pouch
– Stage III • Larger abcesses
• Purulent peritonitis
– Stage IV
• Fecal peritonitis
Diverticulitis
Reasons for Elective Surgery
• CONDITION • REASON
1. Two or more severe attacks of 1. High risk of serious complications
diverticulitis (or one severe attack
in someone younger than 50)
2. Narrowing of the sigmoid colon 2. High risk of serious complications
(lower part of the large intestine)
due to scarring
3. Persistent tender mass in the 3. May be cancer
abdomen
4. X-ray showing suspicious changes 4. May be cancer
in the sigmoid colon
5. Pain when urinating 5. May be a warning of impending
fistula formation between the
large intestine and the bladder
6. Sudden abdominal pain in people 6. Large intestine may have ruptured
taking corticosteroids into the abdominal cavity

Diverticulitis

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Diverticulitis

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Diverticulitis

• Diverticulitis – Fecalith becomes impacted

• Mortality and Morbidity

• Fistulas occur in 5% of patients w/

• CT and barium enema are complementary

• Colon carcinoma may mimic diverticulitis

• Early surgical consultation is important

• Percutaneous catheter drainage

• Some reasons for surgery

• Hinchey staging • Percutaneous

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