Diverticular Disease

Dr. Matt W. Johnson

Introduction & Overview
Pathology
Physiology
Location
Complications
Bleeding
Obstruction
Fistula
Acute Diverticulitis
Management of Acute Diverticulitis


Pathology
Congenital
Acquired
association with Western diets high in refined
carbohydrates and low in dietary fibre
1

Deficiency of vegetable fibre in diet
2

Disordered motility
Hyperelastosis may lead to structure change
Collagen abnormalities
Age
Diverticular disease occurs in over 25% of the
population, increasing with age
3
1
Ferzoco et al Lancet 1998;
2
Simpson et al Br J Surg 2002;
3
Janes et al BJS 2005

Physiology
La Place effects
High intra-luminal pressure
Resultant characteristic protrusion mucosa
Worst at terminal arterial branches
Rectal sparing
?due to complete layer of longitudinal muscle and
large diameter

Physiology and Anatomy
Terminal arterial branches

Penetrate circular muscle

Often lie adjacent to taenia
Location
Classically Sigmoid
In Orient often right-sided
Rectal Sparing

Can occur anywhere
(but considered separately)
e.g. Small bowel see later
Right vs. Left
Complications

Obstruction
Bleeding
Inflammation itis
Fistula
Sepsis
Perforation

May co-exist with IBD
Specimen showing blood in diverticulae
Obstruction in Diverticular Disease
Progressive distension
Single contrast enema will delineate this
Often present like cancer
Diagnosis
often only at operation (opened specimen) or
on histology
Bleeding in Diverticular Disease
Rarely exsanguinating
Often requires repeat transfusion
Consider mesenteric angiography if available
Embolisation (risk of ischaemia and infarction)
Allows targeted resection
Operative intervention uncommon
On table colonoscopy
Exclusion


Re-Bleeding Rates
Re-bleeding rate
Year Percentage
1 9
2 10
3 19
4 25

1
Longstreth Am J Gastro 1997

Other Causes Of Colonic Bleeding
Exclude
IBD
Neoplasm
Angiodysplasia
Ischaemic colitis
Radiation proctitis
Varices

Fistula
Abnormal connection
Commonest communications are
Colovesical
Colovaginal (esp if prev TAH)
Colovesical Symptoms
Pneumaturia
Recurrent infections
Faecalent urine or particulates
Diagnosis of site/communication vs pathology
CD/CRC/TCC

Acute Diverticulitis
Abscess
Peridiverticular
Mesenteric
Pericolic
Perforation
Concealed
Free
Peritonitis (gangrenous sigmoididits)
Purulent or serous or faecal
Local or generalised or pelvic

1
Killingback Surg Clin North Am 1983

Emergency Presentation
Symptoms
Generally unwell
Pain localising to left iliac fossa*
Abdominal distension
Altered bowel habit e.g. diarrhoea
Nausea/Fever
Signs
LIF tenderness
*Beware RIF pain-in right sided diverticulitis and
where sigmoid crosses midline
Systemic signs (T/HR/BP/WCC)
May be palpable on pR at anterior rectal wall
Management
Resuscitation
Analgesia
Bloods
ECG/Catheter/Urine
Rectal examination (+/-sigmoidoscopy)
CXR
AXR
USS
CT Scan
Operative intervention
CXR
AXR
Diverticular disease


CT Scan
Perforated diverticulitis of the sigmoid colon-CT
Diverticulitis
with pericolic abscess

Operative Picture
Perforation
Operative considerations
Serial assessment and clinical judgement
(even if Radiological perforation)
Operative indications
generalized peritonitis
uncontrolled sepsis,
visceral perforation
acute clinical deterioration
At operation
Resection better than no resection
1
Hartmanns vs anastomosis
1
Krukowski & Matheson Br J Surg 1984

Anastomosis
Is there any role for primary anastomosis in the inflamed
bowel?
Consider if fully resuscitated and colorectal Surgeon
Retrograde gun/washout kit
Schilling et al. 2001 Diseases of the Colon and Rectum
diverticulitis with peritonitis
13 patients one stage
42 Hartmanns procedure
7% mortality in both groups
Similar complication rates
Not a study of bowel obstruction
Elective Presentation
Via outpatients
Often milder version of emergency
presentation
Incidental radiological finding
AXR
Contrast study e.g. Barium Enema
CT scan
Rarely if insiduous, an abscess may be found on Barium
Enema as an outpatient


Elective resection for Diverticultis
After recovering from an episode of diverticulitis
the individual risk of an urgent Hartmanns is
1 in 2000 patient-years of follow-up.
Surgery for diverticular disease has a high
complication rate
25% of patients have ongoing symptoms after
bowel resection (IBS/IBD)
No evidence to support the idea that elective
surgery should follow two attacks of diverticulitis.
Further prospective trials are required.
1
Janes et al BJS 2005

Duodenal and Jejunal
Diverticulosis
Separate from colonic diverticulosis.
Most occur in the jejunum and occasionally duodenum.
Jejunal diverticula are acquired protrusions of the
mucosal lining through the muscular wall of the bowel.
Encourages particular bacterial overgrowth.
A combination of alteration of the intraluminal contents
by these bacteria may result in malabsorption
Calcium
Iron
Vitamins D or B12.
Patients may present with anaemia and occasionally
osteomalacia.
Proximal Jejunal Diverticulitis
Incidental Jejunal Diverticular

Proximal Jejunal diverticulitis with
perforation
Questions
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