Diverticular disease
What type of surgery is usually performed for an acute case of diverticulitis with a complication?
1) Hartmann's procedure: resection of involved segment with an end colostomy and stapled rectal stump. 2) Resection, primary anastomosis loop ileostomy.
What is the epidemiology of diverticulosis?
50-60% in the US by age 60, with only 10-20% becoming symptomatic.
What is the most common site for diverticulosis?
95% of people with diverticulosis have sigmoid colon involvement.
What are complications of diverticulitis?
Abscess, diffuse peritonitis, fistula, obstruction, perforation, stricture.
How does diverticulosis present clinically?
Bleeding, which may be massive. -Presents with painless rectal bleeding, particularly in an elderly patient.
What is the diagnostic approach to diverticulosis?
Bleeding: without signs of inflammation, a colonoscopy should be obtained. Pain and signs of inflammation: abdominal/pelvic CT scan.
What are the indications for elective resection of diverticulitis?
Case by case decisions, but usually after two episodes of diverticulitis; should be considered after the first episode in a young diabetic, or immunosuppressed patient or to rule out cancer.
What must be ruled out in any patient with diverticulosis/diverticulitis?
Colon cancer.
What is the most common fistula with diverticulitis?
Colovesical fistula (to bladder).
What are indications for operation with diverticulosis?
Complications of diverticulitis (e.g. fistula, obstruction, stricture) Recurrent episodes Hemorrhage Suspected carcinoma Prolonged symptoms Abscess not drainable by percutaneous approach
What is diverticulosis?
Condition in which diverticula can be found within the colon, especially the sigmoid; diverticula are actually false diverticula in that only mucosa and submucosa herniate through the bowel musculature; true diverticula involve all layers of the bowel wall and are rare in the colon.
What is the best test to diagnose diverticulitis?
Dignose with CT scan and no oral contrast CT will demonstrate fat stranding and bowel wall thickening.
What are the most common causes of massive lower GI bleeding in adults?
Diverticulosis (especially right-sided), vascular ectasia.
When is it safe to get a colonoscopy or barium enema/sigmoidoscopy after an episode of diverticulosis?
Due to risk of perforation, this is performed 6 weeks after inflammation resolves to rule out colon cancer.
How is diverticulosis treated?
High-fiber diet is recommended. Evidence has negated the need to recommend avoidance of nuts, seeds, and popcorn.
What is the initial therapy for diverticulitis?
IV fluids NPO (bowel rest) Broad-spectrum anitbiotics with anaerobic coverage (Cipro, Flagyl) NG suction (as needed for emesis/ileus)
What is diverticulitis?
Infection or perforation of a diverticulum.
How does diverticulitis present clinically?
LLQ pain (cramping or steady) and/or LLQ mass Change in bowel habits (diarrhea) Fever, chills Anorexia, nausea, vomiting Dysuria
Are colonoscopy or barium enema safe to perform in diverticulitis?
No, there is an increased risk of perforation.
What is the pathophysiology of diverticulitis?
Obstruction of diverticulum by a fecalith, leading to inflammation and microperforation.
When is surgery warranted for diverticulitis?
Obstruction, fistula, free perforation, abscess not amenable to percutaneous drainage, sepsis, deterioration with initial conservation treatment.
What laboratory findings are present in diverticulitis?
Occult blood in the stool and mild to moderate leukocytosis may occur with diverticulitis.
What are risk factors for diverticulosis?
People with low-fiber diets, chronic constipation and a positive family history; incidence increases with age.
What is the treatment for diverticular abscess?
Percutaneous drainage; if abscess is not amenable to percutaneous drainage, then surgical approach for drainage is necessary.
What initial imaging is performed in diverticulitis?
Plain-film radiography should be done to rule out free air.
What is the pathophysiology of diverticulosis?
Weakness in the bowel wall develops at points where nutrient blood vessels enter between antimesenteric and mesenteric teniae; increased intraluminal pressures then cause herniation through these areas.
