Diverticular disease

Presented by:farahnaz.kardan

Definitions

Colonicdiverticulum: herniation of mucosa and muscularis mucosa through colonic wall (technically, a false diverticulum)

Diverticulardisease: presence of symptomatic diverticula

Diverticulitis: inflammation and infection associated with diverticula

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Epidemiology

very common in Western world~50% people > 50 y.o.

 .

Barium enema with extensive sigmoid diverticulosis

Etiology fibre diet

stool volume

intraluminal pressure

colonic wall tension

muscular hypertrophy,

pulsion diverticula

tensile strength elasticity

age

Uncomplicated Diverticulitis

Infection, inflammation of diverticulum

Presentation:LLQ pain, tendernessCT:

pericolic soft-tissue strandingcolonic wall thickeningphlegmon

Uncomplicated Diverticulitis:treatmentAcuteBowel restiv antibioticsMerperidine better than morphine3 weeks laterScope to rule out cancer4-6 weeks laterElective resection, if appropriate…

Indications operationfor elective≥ 2 acute attacks, successfully treated

medicallyone attack requiring hospitalization in

patient < 40 y.o.one complicated attackone attack in immunocompromised patientinability to rule out colonic carcinoma

Complicated Diverticulitis

AbscessObstructionDiffuse peritonitis (free perforation)Fistulas, e.g., colovesical, colovaginal,

coloenteric, colocutaneous

Complicated Diverticulitis, Abscess

Hinchey Stage

I pericolic abscess

II retroperitoneal or pelvic abscess

III purulent peritonitis

IV fecal peritonitis

Complicated Diverticulitis, Abscess

Hinchey Stages I (pericolic abscess) and II (retroperitoneal or pelvic abscess)

Pre-op CT-guided percutaneous drainageElective resection, primary re-anastomosisHinchey Stage III (purulent peritonitis)Emergent Hartmann’s procedure, orEmergent resection, primary re-anastomosisHinchey Stage IV (feculent peritonitis)Emergent Hartmann’s procedure

Complicated Diverticulitis, Fistula

Treat acute attackElective resection, primary re-

anastomosis

Investigations

Townsend: Sabiston Textbook of Surgery,17th ed., 2004

Investigations - CT

Air-filled diverticula

Mesenteric stranding

Investigations - CT

Air in bladder

Thickened wall

THE END