Diverticulosis & Diverticulitis

1. Diverticulosis & Diverticulitis Victor Politi, M.D., FACP, FACEP Medical Director St. John’s University, School of Allied Health Physician Assistant Program

2. Diverticulum – A diverticulum is a pouch or a pocket-like opening in the bowel wall, usually in the colon. • The pouch is formed by the hernia of superficial layers of the colon through the weak points in the bowel wall a small pouch in the colon that bulges outward through a weak spot • The occurrence of a diverticulum is known as diverticulosis

3. Normal Abnormal

4. When the pouches become infected or inflamed, the condition is called diverticulitis. • This happens in 10 to 25 percent of people with diverticulosis. • Diverticulosis and diverticulitis are also called diverticular disease

5. Diverticulitis can occur anywhere in the gastrointestinal tract • most commonly observed in the colon. • Small bowel diverticulitis is far less common than colonic diverticulitis. • Asymptomatic diverticulosis is a common condition, but few patients with diverticula develop symptomatic diverticulitis.

6. In about 25% of patients with painful diverticular disease - develops in the bowel wall through the diverticulum leading to infection and inflammation around the colon. • This complication is known as diverticulitis. • The infection usually stays localized, but can spread into the abdomen causing severe diverticulitis.

7. Predisposing Factors • Aging • causes changes in collagen structure- may lead to weakening of the colonic wall. • Colonic motility disorders • Long term Corticosteroid or NSAID use • Genetics • believed to play a role, Asian people tend to have a predominance of right-sided diverticula, while Western people tend to have left-sided disease

8. DiverticulitisSymptoms • Most common symptom -abdominal pain • Most common sign- tenderness around the left side of the lower abdomen • If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. • The severity of symptoms depends on the extent of the infection and complications

9. Diverticulitis Complications • Diverticulitis can lead to • Abscess • Diverticular Hemorrhage • Intestinal fistula • Intestinal perforation • Intestinal obstruction • Sepsis and septic shock

10. Diverticulitis Complications • Infection • Treated with antibiotics • usually clears up after a few days of treatment • Rest the Gut • Abscess - • An abscess is an infected area with pus that may cause swelling and destroy tissue

11. Diverticulitis Complications • Perforation- • Sometimes the infected diverticula may develop small holes (perforations) • The perforations allow pus to leak out of the colon into the abdominal area • If the abscess is small and remains in the colon, it may clear up after treatment with antibiotics. • If the abscess does not clear up with antibiotics, it may require drainage (percutaneous catheter drainage) • Sometimes surgery is needed to clean the abscess and, if necessary, remove part of the colon

12. Diverticulitis Complications • Peritonitis- (an infection of the abdominal cavity) • A large abscess can become a serious problem if the infection leaks out and contaminates areas outside the colon. • Infection that spreads into the abdominal cavity is called peritonitis. • Peritonitis requires immediate surgery to clean the abdominal cavity and remove the damaged part of the colon. • Without surgery, peritonitis can be fatal.

13. Diverticulitis Complications • Fistula- • Abnormal connection of tissue between two organs or between an organ and the skin • When damaged tissues come into contact with each other during infection, they sometimes stick together. If they heal that way, a fistula forms • When diverticulitis-related infection spreads outside the colon, the colon's tissue may stick to nearby tissues. • The organs usually involved are the bladder, small intestine, and skin.

14. Diverticulitis Complications • Fistula • The most common type of fistula occurs between the bladder and the colon. Colovesicular fistula (colon to urinary bladder). • This is observed almost exclusively in men • Also seen in women following hysterectomy • This type of fistula can result in a severe, long-lasting infection of the urinary tract. • Can be corrected with surgery to remove the fistula and the affected part of the colon • Colovaginal and colocutaneous fistulae are much less common

15. Diverticulitis Complications • Intestinal Obstruction • The scarring caused by infection may cause partial or total blockage of the large intestine. • When this happens, the colon is unable to move bowel contents normally. • If the obstruction totally blocks the intestine, emergency surgery is necessary

16. History/Physical • The clinical presentation of diverticulitis depends on: • location • severity of the underlying inflammatory process • and on whether complications are present

17. Imaging Studies • X-rays to make sure the colon has not perforated • CT scan with contrast of the abdomen/pelvis if the diagnosis is unclear • Flexible Sigmoidoscopy and Barium enema only after symptoms are improved (if these tests are done too early, they can cause a colon perforation)

18. Imaging Studies • CT scan of the abdomen is considered the optimal method of investigation in patients suspected of acute diverticulitis. • CT scan is also very helpful in determining the extent of complications of the disease

19. Procedures • Endoscopy is not usually used in the evaluation of acute episodes of diverticulitis because of the possibility of perforation and subsequent development of peritonitis

20. Treatment of diverticulitis • Treatment for diverticulitis focuses on: • clearing up the infection and inflammation • resting the colon (bed rest,liquid diet, pain meds as needed) • preventing or minimizing complications • An attack of diverticulitis without complications may respond to antibiotics within a few days if treated early.

21. Treatment of diverticulitis • Hospitalization is required if: • patients are unable to tolerate oral hydration • if outpatient therapy fails • if notable fever and/or peritoneal signs develop • if pain is severe enough to require narcotic analgesia • or if patients have a chronic underlying medical condition.

22. Treatment of diverticulitis • Surgical treatment is usually necessary in only 20-30% of patients with acute diverticulitis

23. Dietary Management • Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis. • In mild episodes, a clear liquid diet is advised. • Long-term management includes a high-fiber, low-fat, and low-beef diet.

24. Dietary Management • Increasing the amount of fiber in the diet may reduce symptoms of diverticulosis and prevent complications such as diverticulitis. • Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily. • The American Dietetic Association recommends 20 to 35 grams of fiber each day.

25. Dietary Management • Fiber product – • Citrucel or Metamucil once a day. These products are mixed with water and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 ounces of water.

26. Diverticulosis is a very common, and usually a very benign condition • Complications occur only in a minority of patients, and most of them get well with medical treatment alone without any need for surgery