Yair Edden , MD Department of Surgery Shaare-Zedek Medical Center

1. Sigmoid Diverticular Disease YairEdden, MD Department of Surgery Shaare-Zedek Medical Center The Hebrew University School of Medicine Jerusalem, Israel

2. Nomenclature Diverticulum = sac-like protrusion of the colonic wall Diverticulosis = describes the presence of diverticuli Diverticulitis = inflammation of diverticuli

3. Nomenclature True Diverticulum = all layers of the GI wall (mucosa to serosa)e.g. Appendix, Meckel, Congenital False/Pseudo Diverticulum = Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosae.g. Acquired pathology

4. Epidemiology- Sigmoid diverticulosis • Before the 20th century, diverticular disease was rare • Prevalence has increased over time • 1907 First reported resection of complicated diverticulitis by Mayo • 1925 5-10% • 1969 35-50%

5. Epidemiology- Sigmoid divericulosis Increases with age: • Age 40 <5% • Age 60 30% • Age 85 65% Younger patients are diagnosed frequently

6. Endoscopic appearance

7. Double contrast Barium enema

8. CT Scan

9. CT Scan

10. From out side…

11. Anatomic location of diverticuli varies with the geographic location “Westernized” nations have predominantly left sided diverticulosis • 95% diverticuli are in sigmoid colon • 35% can also have proximal diverticuli • 4% have only right sided diverticuli

12. Anatomic location of diverticuli varies with the geographic location Asia and Africa diverticulosis in general is rare and usually right sided • Prevalence < 0.2% • 70% diverticuli in right colon in Japan

13. Pathophysiology • Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

14. Pathophysiology • Law of Laplace: • Pressure = K x Tension / Radius • Sigmoid colon has the smallest diameter resulting in highest pressure zone

15. Pathophysiology • Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers • Segmentation  increased intraluminal pressure  mucosal herniation  Diverticulosis • May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

16. Pathophysiology

17. Lifestyle factors associated with diverticular disease • Low fiber  diverticular disease • Not absolutely proven in all studies but strongly suggested • Western diet is low in fiber with high prevalence of diverticulosis • In contrast, African diet is high in fiber with a low prevalence of diverticulosis

18. Lifestyle factors associated with diverticular disease • Obesity associated with diverticulosis – particularly in men under the age of 40 • Lack of physical activity

19. Lifestyle factors associated with diverticular disease • Do patients need to avoid foods with seeds or nuts?

20. Lifestyle factors associated with diverticular disease • NO!

21. In most cases diverticular disease is a-symptomatic

22. A-symptomatic diverticulosis • Considered ‘a-symptomatic’ • However, some patients will complain of cramping, bloating, irregular BMs, narrow caliber stools • Confused with IBS • Recent studies demonstrate motility abnormalities in patients with ‘a-symptomatic’ uncomplicated diverticulosis

23. Diverticulitis • Diverticulitis = inflammation of diverticuli • Most common complication of diverticulosis • Occurs in 10-25% of patients with diverticulosis

24. Diverticulitis • Micro or macroscopic perforation of the diverticulum • Subclinical inflammation to generalized peritonitis • Previously thought to be due to fecaliths causing • increased diverticular pressure; this is really rare

25. Diverticulitis • Erosion of diverticular wall from increased • intraluminal pressure • Inflammation • Focal necrosis • Perforation • Usually inflammation is mild and microperforation is • walled off by peri-colonic fat and mesentery

26. Diagnosis of Diverticulitis • Classic history: increasing, constant, LLQ abdominal • pain over several days prior to presentation with fever • Crescendo quality – each day is worse • Constant – not colicky • Fever occurs in 57-100% of cases

27. Diagnosis of Diverticulitis • Previous episodes of similar pain • Associated symptoms • Nausea/vomiting 20-62% • Constipation 50% • Diarrhea 25-35% • Urinary symptoms (dysuria, urgency, frequency) 10-15%

28. Diagnosis of Diverticulitis • Diagnosis can be made with typical history and • examination • Radiographic confirmation (CT) is often… (100%) • performed • Rules out other causes of an acute abdomen • Determines severity of the diverticulitis

29. CT Scan

30. CT Scan

31. Simple vs. Complicated Diverticulitis • Complicated diverticulitis = Presence of • macroperforation, obstruction, abscess or fistula • Simple diverticulitis = Absence of the above • complications

32. Simple vs. Complicated Diverticulitis • Complicated diverticulitis = Presence of • macroperforation, obstruction, abscess or fistula • Simple diverticulitis = Absence of the above • complications

33. Simple Diverticulitis Hospitalization !?

34. Simple Diverticulitis • IV Antibiotics • Bowel rest, clear liquids for 2-3 days • Based on clinical findings advance diet (low residue) • and PO antibiotics

35. Simple Diverticulitis After resolution of attack - high fiber diet with supplemental fiber

36. Simple Diverticulitis • Follow-up: Colonoscopy in 4-6 weeks • Purpose • Exclude neoplasm • Evaluate extent of the diverticulosis

37. Simple Diverticulitis • Prognosis after resolution • 30-40% of patients will remain asymptomatic • 30-40% of patients will have episodic abdominal • cramps without frank diverticulitis • 20-30% of pts will have a second attack

38. Simple vs. Complicated Diverticulitis • Complicated diverticulitis = Presence of • macroperforation, obstruction, abscess or fistula • Simple diverticulitis = Absence of the above • complications

39. Complicated Diverticulitis • Hinchey classification • Pericolic abscess • Distal abscess • Purulent peritonitis • Fecal peritonitis Hinchey EJ et al. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978

40. Complicated Diverticulitis • Hinchey classification • Pericolic abscess • Distal abscess • CT guided drainage

41. Complicated Diverticulitis Hinchey classification 3. Purulent peritonitis 4. Fecal peritonitis Surgery

42. Complicated Diverticulitis Hartman’s Procedure

43. Complicated Diverticulitis • Other clinical presentation • Bleeding • Stricture • Fistula

44. Complicated Diverticulitis Other clinical presentation Bleeding

45. Complicated Diverticulitis

46. Complicated Diverticulitis

47. Complicated Diverticulitis • Most only have symptoms of bloating and diarrhea but no significant abdominal pain • Painless hematochezia • Start – stop pattern; “water faucet” • Diverticulitis rarely causes bleeding • Right > Left

48. Complicated Diverticulitis Other clinical presentation Stricture

49. Complicated Diverticulitis • Chronic inflammation • Bloating • Constipation

50. Complicated Diverticulitis Other clinical presentation Stricture Surgery