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Left and Right Sided Diverticular DiseaseTwo Entities?
Mr Richard CohenSt. Mark’s Hospital, Harrow
University College Hospital, London
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Diverticular Disease
• Solitary Caecal Diverticulum
• Left Sided Diverticular Disease
• Right Sided Diverticular Disease
• Pan Colonic (Total) Diverticular Disease
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Diverticular Disease
Diverticular Disease?Normal
DIVERTICULOSIS
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Presentation ---Acute
Right• Bleeding• RIF Pain
– Peritonitis– Phlegmon– Abscess
Left• LIF Pain
– Obstruction– Phlegmon– Peritonitis– Abscess
• Bleeding
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Presentation ---Chronic
Right• Anaemia
Left• Anaemia• Constipation• Pain• Fistulation
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Diverticular disease - uncomplicated
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Diverticular disease - pericolic abscess
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Solitary Caecal Diverticulum• 1 in 1000 emergency laparotomies• First recorded: 1912 Potier
» 52% anterior» 15% posterior» 14% lateral wall» 7% medially (Wagner and Zollinger 1961)
• “True” diverticula (muscle fibres in wall)– Parker and Seargent 1957– Anscombe 1967
• Congenital• Only present with complication
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Classification at OperationGreaney and Snyder 1957Am J. Surg
• Grade I and II– Inflammation of
diverticulum or DD Mass
• Grade III and IV– Pus or
perforation
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Country Studies n Caecum Ascending Transverse Descending Sigmoid Total Colon Colon Colon Colon Colon
UK 2 627 1.5 6.5 6 20 58.5 7.5USA 6 5384 3 4 4.7 17.5 69.2 7.5Norway 1 90 3 6 5 23 63Sweden 1 546 0 2 4 14 78 3Finland 2 458 0 6.5 10.5 26.5 56 1.5Japanese 1 82 81 R Colon 11 L Colon 8Hong Kong 1 215 13 36 20 17 13Israel 1 112 2 15 5 24 38 16Australia 1 90 6 R Colon 79 L Colon
Diverticular Disease Worldwide
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World Distribution of DD
RIGHT SIDE
• Japan• Korea• China• Singapore• Taiwan• Tailand
LEFT SIDE
• Europe• USA• Brazil• South Africa• Australia• India
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Mechanism of Left sided DD• Abnormal thickening
with ageing• Collagen abnormality• Increased intraluminal
pressure • Segmentation
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Mechanism of Left sided DD
• Mucosa and submucosa herniate
• Locus minorisresistentia
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Ageing and Diet
• Uncommon under 40• 60% over 70 have DD• Environment of the colon rather than its age
(Painter and Burkitt 1975)
• Fibre43881 USA males– Fibre associated with marked decrease risk of symptomatic DD
• Meat3105 colonoscopies with dietary interviews– Right sided diverticulosis correlates with past meat consumption
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Mechanism of Right Sided DD
Japan• Large increase in detection
– 1050’s…..1%– 1970’s…..20%
• Younger age
• Decrease in fibre– 1946…..25.0g/day– 1991…..14.5g/day
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Correlation with dietary fibre intakeMunakattaA et al, Tohoku J Exp Med 1993
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Site of Involvement by Age GroupYoshidaY, Inoue M
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Birth cohort analysis Hirosaki University Hospital Nakaji et al. Int J Colorectal Dis (2002)
• 1945-54 ♦
• 1935-44• 1915-24• 1905-14
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Intraluminal Pressure Right DD
Colonoscopy with catheter tip transducer• 13 R sided DD• 10 Normal• Injection of neostigmine more frequent high pressure waves• Higher motility index Sugihara K et al Gut 1983
Ascending colon pressure higher with right sided DD than sigmoid DD
Sasaki et al. Nankodo, Tokyo 1990
Intraluminal pressure higher in right colon in patients with right sided DD than those without diverticula
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Pathological Features Right Sided DD
• Almost all are pseudodiverticula• Abnormal thickness of colon wall• Number of haustra per constant distance of
ascending colon is greater than controls• Abnormal shortening of colon• Right sided DD are at points where artery
penetrates colon wall
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Detection rates of DD in Hawaiian Japanese and Mainland JapaneseNakaji et al. Int J Colorectal Dis (2002)
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Nakaji, Danjo et al In J Colorectal Dis 2002
∑ vs“Omicroid Colon”
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Clinical Behavior of Left Sided DD
Infective Complications• Diverticulitis• Diverticular Phlegmon• Diverticular Abscess• Diverticular Perforation
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Clinical Behavior of Left Sided DD
Other Complications• Fistulation
– Bladder – Vagina
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Clinical Behavior of Left Sided DD
Other Complications• Stricture formation• Obstruction• Bleeding
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Clinical Behavior of Right Sided DD
Singapore General Hospital Wong,Soong-Kuan et al. DCR 1997
• 188 Patients• Mean Age 65.1 (SEM 13.9)• Women presented 8.4 years later than men• Right sided DD 42%• Left sided DD 34%• Pan colonic DD 24%
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Clinical Behavior of Right Sided DD
Massive Rectal Bleeding (n=85)• Right sided DD 49.4%• Left sided DD 16.5%• R + L DD 34.1%Surgery for bleeding• Right sided DD 41%• Left sided DD 7%
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Clinical Behavior of Right Sided DD
Diverticulitis (n=65)• Right sided DD 38.5%• Left sided DD 49.2%• R + L DD 12.3%
Surgery more common for left sided diverticulitis
Fistulation, rare, but predominantly left sided DD
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Clinical Behavior of Right Sided DDObstruction (n=21)• Right sided DD 38.1%• L sided DD 42.9%• R + L DD 19%
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Management of Diverticulosis
Right Side• ? Fibre• Laparoscopic resection
Right hemicolectomy
Left Side• Fibre and advice• Laparoscopic resection
Left Hemicolectomy
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Management of DiverticulitisRight Side• Often get surgery as mimic
appendicitis unless CT • If known conservative
– Drip– Suck– Antibiotics– Monitor
Failure of conservative Rx leads to surgery
Right Hemicolectomy
Left Side• Conservative
– Drip– Suck– Antibiotics– Monitor
• CT drain abscessFailure of conservative Rx
leads to surgeryHartmannsAnterior resection
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Management of Diverticular Bleeding
• Resuscitation• Assessment• Angiography• Right Hemicolectomy• Left HemicolectomyIF IN DOUBTTAKE IT ALL OUT• Sub Total Colectomy and Ileostomy
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Caecal Mass/ Sigmoid Phlegmon
Conservative treatmentUnless• Rising pulse• Worsening sepsis• Increasing pain• Generalised tenderness• Exclude cancer? Interval laparoscopic resection
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Different Entities?
CongenitalAcquiredGenetics
YoungOld Age
CommonRareBleeding
UnusualCommonInflammatory Complication
Slightly higherAbnormally high
IntraluminalPressure
AbsentRemarkableMuscle Abnormality
Right SidedLeft Sided