Diverticular disease

1. Diverticular disease Dr. Simon Ng Associate Professor Division of Colorectal Surgery The Chinese University of Hong Kong Intensive Surgery Course for Medical Year 5 (2006/2007)

2. Diverticulum • A sac-like protrusion of mucosa through the muscular colonic wall • Protrusion occurs in weakareas of the bowel wall where blood vessels (vasa recta) penetrate

3. Contains only mucosa and submucosa covered by serosa False diverticulum

4. Diverticular disease spectrum Diverticulosis Diverticulitis Diverticular bleeding

5. Diverticulosis • Presence of diverticula without inflammation

6. Diverticulitis • Presence of diverticula with inflammation and subsequent perforation • Uncomplicated diverticulitis: • Peridiverticulitis or phlegmon • Complicated diverticulitis: • Abscess, fistula, perforation, obstruction

7. Hinchey classification • Stage I: pericolic abscess • Stage II: distant abscess (retroperitoneal/pelvic) • Stage III: generalized suppurative peritonitis (abscess ruptured) • Stage IV: faecal peritonitis (free rupture of a diverticulum) Hinchey EJ et al. Adv Surg 1978; 12: 85-109.

8. Clinical Approach to LGIB Covered already in previous lecture! Diverticular bleeding

9. Age in years Prevalence: age Prevalence increases with age Young-Fadok TM et al. Curr Prob Surg 2000; 37: 459-514.

10. No apparent sex predilection Prevalence: gender

11. Prevalence: geographical variation ‘A disease of western civilization’ High High Low Low High High: up to 45% Low: ~ 0% Painter NS and Burkitt DP. BMJ 1971; 2: 450-454.

12. Diverticular disease location In Asian populations, >70% of patients have diverticula in theright colon In European and US populations, 90% of patients have diverticula in the sigmoid colon and only 15% have diverticula in the right colon Stollman N and Raskin JB. Lancet 2004; 363: 631-639.

13. Colonic diverticulosis in HK:distribution pattern and clinical significance • 858 DCBE; prevalence25.1% 87.9% have right-sided colonic involvement Chan CC et al. Clin Radiol 1998; 53: 842-844.

14. P Cause and pathogenesis Colonic wall weakening  Intraluminal pressure Age-related changes Segmentation Dietary fibre deficiency Simpson J et al. Br J Surg 2002; 89: 546-554.

15. Age-related changes All these changes lead to an irreversible state of contracture and result in  resistance of the colonic wall Structural changes in colonic wall of patients with diverticulosis • Mychosis • Thickening (neither hypertrophy nor hyperplasia) of the circular muscle layer • Shortening of the taeniae coli • Luminal narrowing • elastin deposition in taeniae coli •  type III collagen synthesis •  collagen crosslinking

16. Diverticulum Contraction Contraction Segmentation Laplace’s law P = k T/R Painter NS et al. Gastroenterology 1965; 49: 169-77.

17. Dietary fibre deficiency • Diverticulosis is a ‘deficiency disease’: dietary fibre deficiency • Smaller stool volume • Longer transit time • Increases intraluminal pressure Painter NS and Burkitt DP. BMJ 1971; 2: 450-454.

18. Asymptomatic 70% Natural history of diverticulosis

19. Clinical features of diverticulosis • 70% remains asymptomatic • Some patients have symptoms of mild abdominal cramping, bloating, flatulence, irregular bowel habit • These nonspecific symptoms overlap considerably with those of irritable bowel syndrome • Diagnosis: DCBE or colonoscopy • Treatment: dietary fibre, anticholinergic or antispasmodic agents

20. Natural history of diverticulitis

21. Clinical triad Clinical features of diverticulitis • LLQ pain (93-100%) • Fever (57-100%) • Leukocytosis (69-83%) • Generalized peritonitis • Fistulae to bladder, vagina, or skin • Intestinal obstruction due to edema, bowel spasm, compression from an abscess, or stricture after recurrent attacks

23. Diagnosis of diverticulitis • Initial evaluation by Hx, P/E, CBP, urinalysis, and X-rays (CXR and AXR) • It has been recommended that when the clinical picture is clear additional tests are not necessary to make a diagnosis • If the diagnosis is uncertain, other tests may be performed

24. Other diagnostic tests for diverticulitis • Water-soluble contrast enema • CT scan • DCBE and colonoscopy are contraindicated during the acute attack • However, full LB Ix with DCBE or colonoscopy should be performed when the acute attack has resolved: to r/o cancer

25. CT scans of diverticulitis

26. CT scans of diverticular abscesses Large air-containing divertciular abscess Large divertciular abscess with penetration into retroperitoneal structures Contained abscess in sigmoid diverticulitis Hinchey stage I Hinchey stage II

27. Contrast extravasation Hinchey stage III Perforated right-sided diverticulitis

28. Bladder Sigmoid Colovesical fistula

29. Sigmoid Vagina Colovaginal fistula

30. Terminal ileum Sigmoid Coloenteric fistula

31. Sigmoid diverticulitis with stricture

32. Treatment of diverticulitis • Medical therapy • Successful in 70-80% of patients • Percutaneous therapy • For drainage of pericolic abscess (Hinchey stage I and II) • Surgical therapy • Emergency (Hinchey stage III and IV) or elective operation

33. Medical therapy • In the absence of systemic symptoms and signs, patients may be treated on an outpatient basis with low residue diet and oral antibiotics (7-10 days) • Hospitalization is required for increasing abdominal pain, fever, or inability to tolerate oral intake • Need bowel rest, observation and IV antibiotics • 70-80% of patients respond to medical therapy – improvement should be apparent within 48-72 hours

34. CT-guided drainage of pericolic abscess

35. Emergency surgery • Indications for emergency surgery: • Failed medical treatment • Abscess could not be drained by percutaneous methods • Generalized peritonitis • Intestinal obstruction

36. Natural history of diverticulitis and elective surgery

37. Elective surgery • Indications for elective surgery: • Patients who have had one episode of complicateddiverticulitis (abscess, obstruction, fistula) • Patients who have had two episodes of acutediverticulitis severe enough to require hospitalization • Young and immunocompromised patients after one attack of acute diverticulitis (controversial)

38. Surgical principles • Control of sepsis • Resection of all diseased tissues • Restoration of intestinal continuity if possible (with or without protective stoma) • Minimizing morbidity and mortality

39. Surgical options • Outdated 3-stage colostomy and drainage • Hartmann’s procedure • Primary resection, anastomosis and diversion • Primary resection and anastomosis (on-table lavage)

40. 3-stage operation

41. First stage Second stage Hartmann’s procedure Resection, end colostomy, and mucus fistula Closure of stoma Resection, anastomosis, and proximal diversion 2-stage operation

42. 1-stage operation

43. Anastomosis or stoma • 2 good endsanastomosis • 2 good ends/poor conditionanastomosis +diversion • 1 good end/poor conditionanastomosis +diversion • 2 bad endsHartmann’s operation

44. Laparoscopic colectomy for diverticulitis • Considered to be the procedure of choice for uncomplicated diverticulitis • Also feasible for complicated diverticulitis (Hinchey Stage I and II)