DIVERTICULAR

DISEASE

Group-8
GROUP MEMBERS

 MOHAMMED ASLAM 16-0704-402

 TALARI PALLAVI 16-0705-165
 TUMATI LAHARI 16-0719-829
 TALLA PRAVALLIKA 16-0776-254
 PATAN SUMIYA 16-0752-641
 PALADUGU VINEETH 16-0755-376
 SATTI SURENDRA 16-0711-800
 SATTI SRI LAKSHMI 16-0707-659
 VINJAM POOJITHA 16-0782-795
 SAMBA BALA VENKATA MANIKANDAN 16-0769-579
 SINGUPURAM DIVYA SAMHITA 16 -0756-928
 PATNEEEDI SATYA VAMSI 16-0697-369
 Diverticular disease is a very common condition which
occurs due to the ageing of muscles that make up the
wall of the large bowel. Small bulges develop as the
internal layer of the bowel pushes outwards through the
weakened muscle to form pockets called diverticulae.

 There are two main types of diverticular disease -

diverticulitis and diverticular bleeding.
EPIDEMOLOGY

 5 th most costly gastrointestinal disorder in the united

states.

 Diverticulosis af fects 70% of population above the age

of 80.

 Mean age at presentation of the disease is 59 but now it

is shifting to younger population.

 Common in men and women

 Men-higher incidence of diverticular bleeding

 Women-more episodes of obstruction or stricture

ANATOMY

 Two types of diverticula occur in the intestine:

 True diverticula – is a sac like herniation of the whole

bowel wall.

 False diverticula(pseudo diverticula) – it involves only

protrusion of the mucosa and submucosa through the
muscularis propria of the colon .

 The type of diverticula af fecting the colon is pseudo

diverticula.

 Most commonly af fected areas -left and sigmoid colon

PATHOPHYSIOLOGY

 Diverticulitis is inflammation of a diverticulum.

 Main cause is low fiber diet, and onset of diverticulitis
would occur acutely when these diverticula become
obstructed.
 It occurs at the point where nutrient artery or vasa recti
penetrates muscularis propria resulting in a break in
colonic wall.
 This anatomic restriction may be a result of the relative
high pressure zone in the sigmoid colon .
 As a result the vasa recti is either compressed leading to
perforation or bleeding.
RISK FACTORS

 Age

 Obesity

 Smoking

 Lack of exercise

 Low fiber diet

 Intake of medications like opioids and steroids

 DIVERTICULAR BLEEDING

 In patients grater than 60 years of age hemorrhage from

colonic diverticulum is the most common cause of
hematochezia
 Only 20 percent of people with diverticulosis will have GI
bleeding
 Risk factors for bleeding-Hypertension,
Atherosclerosis
usage of aspirin and NSAIDS
 Self limited
 Stop spontaneously with bowel rest
 Rebleeding-25%
 Initial localization of diver ticular bleeding may include
colonoscopy,multi planar CT angiogram, nuclear medicine
tagged red cells scan
 If stable-ongoing bleeding is best managed by angiography
 If located the vessel can be successfully occluded in 80% of
patients
 Follow up for colonoscopy should be done for any evidences for
colonic ischemia
 Alternatively a segmental dissection for colon should be done to
eliminate the risk for fur ther bleeding with more advantageous
in patients on chronic anticoagulation
 Long term results-40 months(more than 50%)
-treated with highly selective
angiography(definitive treatment)
- selective infusion of vasopressin
Complications-Myocardial infraction
Intestinal ischemia
Recurrence
 If unstable or 6-unit bleed in 24hrs
-Surgery
 If identified-segmental resection
 If unidentified-total colectomy
 No sever comorbidities -surgical resection+primary
anastomosis
 A higher anastomotic leak rate has been reported in patient
who received greater than 10 units of blood
DIVERTICULITIS

 Acute uncomplicated diverticulitis presents with

- Fever

-Anorexia,

-Left lower quadrant abdominal pain,

-Obstipation
 In less than 25% of cases patients may present with
generalized peritonitis indicating the presence of
diverticular perforation .

 Laboratory investigation demonstrate leukocytosis

 Diagnosis is best made on CT the with the following

findings

-Sigmoid diverticula

-Thickened colonic wall>4mm

-Inflammation within the periodic fat

 Symptoms of irritable bowel syndrome may mimic those of
diverticulitis, therefore suspected diverticulitis that does not
meet CT criteria are is not associated with leukocytosis or
fever is not diverticular disease.

 Colonoscopy should be performed 6 weeks after an attack of

diverticular disease.

 Complicated diverticulitis - A diverticular disease associated

with an abscess or perforation and less common with a
fistula.

 Perforated diverticular disease is staged using Hinchey

classification system.
HINCHEY CLASSIFICATION
Stage Classification
I Confined pericolic abscess

II Distant abscess (retroperitoneal or pelvic)

III Generalized peritonitis caused by rupture of a

pericolic or pelvic abscess (not communicating
with the colonic lumen because of obliteration of
the diverticular neck by inflammation)

IV Fecal peritonitis caused by free perforation of a

diverticulum (communicating with the colonic
lumen)
 In complicated diverticular disease with fistula
formation common locations include cutaneous vaginal
or vesicle fistulas.

 These conditions present with either passage of stool

through the skin or vagina or the presence of air in the
urinary stream.

 Colovaginal fistulas are common in women who have

undergone hysterectomy.
MEDICAL MANAGEMENT

Asymptomatic Diverticular Disease

 It is best managed by diet alterations.
 Patients should be instructed to eat fiber enriched diet
that includes 30g fiber each day.
 Supplementary fiber products such as Metamucil,
Fibercon or Citrucel are useful.
 Avoid smoking
Symptomatic uncomplicated Diverticular Disease
 Disease with confirmation of inflammation and infection
within the colon should be treated initially by antibiotics
and bowel rest.
Acute Diverticulitis :-
 75% of patients hospitalized for acute Diverticulitis will
respond to Non Operative treatment with a suitable
antimicrobial regimen.

 Antimicrobial coverage – Trimethoprim/

Sulfamethoxazole or Ciprofloxacin and Metronidazole (
Target gram -ve Rods and anaerobic bacteria).
 These agents do not cover Enterococcus and the
addition of Ampicillin is added to the regimen for non
responders is recommended.

 Alternatively single agent therapy with a third

generation penicillin such as IV Piperacillin or Oral
Penicillin/ Clavulanic Acid may be ef fective.

 The usual course of antibiotics 7 – 10 days.

 Patient should Remain on a limited diet until there pain

resolves.
 The use of antibiotics inflammatory Medications such as
Mesalazine have a decreased recurrence as symptomatic
disease.
 Treatment strategies targeting dysbiosis in Diverticular
disease are also beneficial .
 Probiotics containing ‘Lactobacillus acidophilus' and
“Bifidobacterium Strains ” have been shown to prevent
recurrence of diverticulitis.
 Rifaximin ( a poorly absorbed Broad – Spectrum Antibiotics)
 It is associated with 30% less frequent recurrent symptoms
from uncomplicated diverticular disease.
 SURGICAL MANAGEMENT

 Preoperative risk factors influencing postoperative mor tality

rates include higher American society of Anesthesiologists
physical status class and pre existing organ failure.
 AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL
STATUS CLASSIFICATION SYSTEM.

P1 A normal healthy patient

P2 A patient with mild systemic disease.
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life.

P5 A moribound patient who is not expected to survive without the operation.

P6 A declared brain –dead patient whose organs are being removed for
donation purposes.
 For uncomplicated diverticular disease, medical therapy
can be continued beyond two attacks without an
increased risk of perforation requiring a colostomy.
 However, patients on immunosuppressive therapy, in
chronic renal therapy, in chronic renal failure, or with a
collagen-vascular disease have a fivefold greater risk of
perforation during recurrent attacks.
 Surgical therapy is indicated in all low surgical risk
patients with complicated diverticular disease.
 The goals of surgical management include controlling
sepsis, eliminating complications such as fistula or
obstruction, removing the diseased colonic segment, and
restoring intestinal continuity.
 The goals must be obtained while minimizing morbidity
rate, length of hospitilization,and cost in addition to
maximizing the survival and quality of life.

 Failure may result in recurrent disease.

 The current options for uncomplicated diverticular

disease include open sigmoid resection or a
laparoscopic sigmoid resection .

 The benefits of laparoscopic resection over open

surgical techniques include early discharge atleast by
one day, less narcotic useless postoperative
complications, and early return to work.
 The options for the surgical management of
complicated diverticular disease:
HINCHEY OPERATIVE PROCEDURE ANASTO OVERALL
STAGE MIC LEAK MORBIDITY
RATE,% RATE%
I Resection with primary anastomosis without 3.8 22
diverting stoma.
II Resection with primary anastomoses +/- 3.8 30
diversion
III Hartmann’s procedure vs diverting colostomy 0 vs 6
and omental pedal graft. mortality
----
IV Hartmanns procedure vs diverting colostomy 6 vs 2
and omental pedicle graft. mortality
RECURRENT SYMPTOMS

 Occurs in 10 percent of people

 Follows inadequate surgical resection

 Retained segment of diseased rectosigmoid colon is

associated with twice the incidence of recurrence

 Presence of irritable bowel syndrome