Diverticular DiseaseSuman Raj Baral

• An abnormal pouch, abnormal sac or pouch protruding from the wall of a hollow organ.

True Vs False Diverticulum

Contains all layers of Intestine

Lacks a portion of normal bowel wall

Occurring in human colon are protrusion of mucosa through muscular layers of the intestine

Termed as pseudodiverticula

Nomenclature• Diverticulum = sac-like protrusion of the colonic wall

• Diverticulosis = describes the presence of diverticuli

• Diverticulitis = inflammation of diverticuli

Risk Factors• Rare in individuals before 30 , but at least 2/3rd of Americans develop

diverticulitis by 80 years• Postulated that decreased consumption of unprocessed cereals and

increased consumption of sugar and meat are responsible factors for diverticulitis

• Incidence increases with increasing age

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

Pathophysiology

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

• Most commonly confined to Sigmoid colon in 50% of diverticulosis followed by 40 % in Descending Colon, and entire colon in 5-10% of cases.

Usually characterized by muscular thickening of Sigmoid Colon

Mucosa

Submucosa

Muscularis

Serosa

Vasa recta

Pathophysiology

Law of Laplace: P = kT / R

Pressure = K x Tension / Radius

Sigmoid colon has small diameter resulting in highest pressure zone

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

DIVERTICULITIS• Result of perforation of colonic diverticulum• Misnomer- actually an extraluminal pericolic infection caused by

extravasation of faeces through the perforated diverticulum• Mostly involved is Sigmoid Colon

Clinical FeaturesSymptoms• Left lower quadrant abdominal pain radiating to left groin or back• Alteration in bowel habit• Fever, chills and urinary urgency

Physical Findings

• Depends on Site of perforation, amount of contamination, and presence or absence of secondary infection of adjacent organs

• Tenderness over left lower abdomen, tender mass suggestive of abscess

• Abdominal Distension if a/w ileus or obstruction• Rectal/vaginal examination may reveal pelvic abscess

Diagnosis• Four diagnostic modalities considered• CECT abdomen- reveals location of infection, extent of inflammatory

process, presence and location of abscess, sympathetic involvement of other organs, secondary complications such as ureteral obstruction or a fistula to a bladder

• CT guided drainage of abscess can be done.

• USG Abdomen/pelvis :Percutaneous drainage under USG guidance

• Barium Enema- no significant role- water soluble can be used- no chances of barium fecal peritonitis

• MRI

Described as broad clinical spectrum of disease process

Hinchey Stage

I pericolic abscess

II retroperitoneal or pelvic abscess

III purulent peritonitis

IV fecal peritonitis

Uncomplicated Diverticulitis

• May be treated with antibiotics if not associated with abscess, fistula formation

• Avoid morphine• Usually antibiotics respond within 48 hrs• Once symptoms subside, other investigations to be carried out to rule

out carcinoma – Colonoscopy• Barium Enema- delineates the extent of disease but cancerous lesions

may be missed as they may be hidden within contrast filled diverticula

• 1st attack- treat with high fibers• 2nd attack- chances are low with less than 25%• Treat younger patients as per the older patients of above 50 .• Recurrent attacks- Surgical management to be considered• Sigmoidectomy to be considered after 2 uncomplicated attacks• However, no significant difference in mortality and morbidity between 1-2

attacks vs multiple attacks• Immunocompromised Patients- Selective Colectomy after single attack• Laparascopic Approach better than midline approach- less hospital stay

Complicated Diverticulitis• Usually confined to pelvis• Pelvic abscess presents with pain, fever, and leucocytosis• Abdominal/pelvic/rectal examination : reveals tender, fluctuant mass• CT/MRI/USG- confirms the diagnosis

• USG/CT guided percutaneous drainage if the size is greater than 2 cm• Occasionally, drained by transanal approach into rectum along with IV

antibiotics• Elective surgery after 6 weeks- thickened part of sigmoid to be

removed followed by colo-rectal anastomosis• If diverticula is present throughout the colon, it’s mandatory just to

remove the sigmoid colon rather than all segment of colon

Fistula

• May occur between sigmoid colon and skin, bladder, vagina or small bowel

• Most common cause for fistula between colon and bladder• Sigmoid-vesicular fistula more common in men than women

Symptoms• Pneumaturia, Fecaluria, recurrent UTI• Prostatic hypertrophy in men with distal urinary tract obstruction• CT – demonstrates air in the bladder• Cystoscopy reveals cystitis and bullous edema at site of fistula and aso

helpful to r/o bladder cancer • Colonoscopy- examine sigmoid mucosa and exclude colon cancer or

Crohn’s Disease

• Treatment : control infection and inflammation- Antibiotics • One Stage Operation : taking down fistula and excising sigmoid colon

and anastomosis between sigmoid colon and rectum• Bladder defect need not be closed as it heals spontaneously after

drainage with foley catheter for 7 days• Large defects may require suturing with drainage

Generalized Peritonitis• Usually two causes

Perforated Diverticulum : peritoneal contamination with faeces Abscess rupture : contamination with pus in peritoneal cavity• Ultimately leads to generalized peritonitis• Presentation : Diffuse abdominal tenderness, with guarding

Elevated WBC, fever, tachycardia, hypotension

• Treatment : Immediate Laparatomy with excision of diseased segment with colostomy using non inflammed descending colon – Hartmann’s Procedure

• IV antibiotics • Taking down colostomy after 10 weeks – anastomosing between

descending colon and rectum

Obstruction• Via two mechanism :

• Stricture : • narrowing of sigmoid because of muscular hypertrophy of the bowel wall• Difficult to differentiate from malignant stricture• Treated with Sigmoidectomy

• Small Bowel Obstruction : due to adherence to phlegmon or abscess

Diverticular associated Colitis• Rectal Sparing is the associated finding to differentiate from UC

however confounded with Crohn’s Colitis• Characterized by prolapse of mucosa associated with diverticula,

hyperplasia of the glands, and muscularization of lamina propria• Erosions and hemosiderin deposition may mimic UC/CD• C/F: Tenesmus, hematochezia, diarrhoea• Colonoscopy – focal erythema, submucosal ecchymosis, erosions and

ulcers

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