Diverticular Disease

1. Diverticular Disease Firas Obeidat,MD

2. Introduction Acquired herniations of mucosa through the muscle wall between the mesenteric and antimesenteric taenia. Most common structural abnormality of the bowel. In developed countries the prevalence of diverticular disease has increased during the last century: - detection - diet - aging

4. Incidence < 40 yr = 5% > 85 yr = 85% Sigmoid colon is involved in over 95% of patients affected with diverticulosis In western countries left-sided diverticulitis predominates with right-sided diverticulitis occuring in only 1.5% 10-25% of pts will develop diverticulitis

5. Etiology low fiber diet ( high fiber diet protect against diverticulitis not diverticulosis) structural changes due to aging decreased physical activity, obesity. smoking. constipation from any cause

6. Morphologic features Macroscopic appearance: thickening and shortening of the bowel decrease in caliber and increase in intra luminal pressure mesocolon is also foreshortened, possibly as a result of chronic inflammation.

7. Presentation High incidence of diverticulosis, but clinical manifestations are relatively infrequent. symptomatic but uncomplicated diverticular disease ( chronic symptoms with no history of diverticulitis. complicated diverticulosis

8. Cont. diverticulitis: uncompicated diverticulitis: - local inflammation ( microperforation) - accounts for 75% of cases - classical triad ( localized tenderness, fever and leukocytosis complicated diverticulitis: - obstruction. - abscess or fistula formation. - free perforation.

9. Complications Fistula ( 5% of complicated diverticulitis) Spontaneous iatrogenic Types: colocutaneous: - spontaneous. - post abscess drainage. - postoperative colovesical: - most common. - more in males. - recurrent urinary sepsis, urgency, pneumaturia. - cystoscopy, CT, barium enema

10. Cont. coloenteric: - abscess discharge through the small bowel. - diarrhea. - may be asymptomatic. colovaginal: - passage of flatus and feces through the vagina. - recurrent vaginal infection. - more common after hysterectomy.

11. Cont. Bleeding: pathogenesis. with angiodysplasia are the most common cause of massive lower GI bleeding ( usually associated with diverticulosis rather than diverticulitis. colonoscopy is mandatory to exclude malignany. diagnosis stops spontaneously in most cases rebleeding rate is high treatment: colectomy, embolization

13. Cont. Obstruction: luminal stenosis or extrensic compression from an abscess. small bowel obstrucion or colonic obstruction treatment: Hartman‘s, tubular resection, stent. DD with malignancy!!!!

14. Cont. Abscess: most common complication of acute diverticulitis. Symptoms. signs: palpable mass. treatment: small pericolic with antibiotics and bowel rest, CT or U/S guided drainage for larger or un resolving abscesses.

15. Classification of diverticulitis Hinchey classification: Stage I:  diverticulitis with associated pericolic abscess. Stage II:  diverticulitis associated with distant abscess (pelvic) Stage III:  diverticulitis associated with purulent peritonitis. Stage IV:  diverticulitis associated with fecal peritonitis. Stages I and II: antibiotics and drainage. Stages III and IV: occurs in 1-2% of cases Mortality 20-30% treatment: surgery

16. Investigations CT scan (diagnostic and therapeutic) Contrast study ( not indicated in acute diverticulitis ) Colonoscoy (after resolution of acute attack)

17. Management The majority can be managed conservatively 15-25% will require surgery during the initial complicated attack. For those who experienced 2nd attack, 60% of them will have complications. After recovery from the 3nd attack, only 10% remain asymptomatic Recovery after the first attack can be expected in over 70% of patients versus 6% after the third episode.

18. Cont. Indications for surgery: * colonic obstruction * fistula * in some cases of bleeding * recurrent diverticulitis. one attack in certain subgroups:

19. Cont. 1. young, fit patients: ?????????? 5% incidence more in male more malignant course. the majority have severe recurrence. more aggressive policy in surgical treatment 2. immunocompromised patients

20. Cont. -The American Society of Colon and Rectal Surgeons has appropriately recommended consideration of elective sigmoid colectomy after recovery from acute diverticulitis on a case-by-case basis, with the decision based on the: Age comorbid disease the frequency and severity of the attacks whether symptoms persist after the acute episode

21. Cont. Emergent Acute Diverticulitis with Localized Peritonitis: - microperforation - most responded to conservative treatment - patients should have colonoscopy few wks after improvement Emergent Acute Diverticulitis with Generalized Peritonitis: - macroperforation - Hartmann‘s procedure - primary anastomosis ?? Role of MIS:

26. Thank you