2. Nomenclature
Diverticulum = sac-like protrusion of the
gut wall
Diverticulosis = describes the presence
of diverticuli
Diverticulitis = inflammation of diverticuli
3. Epidemiology
Before the 20th century, diverticular
disease was rare
Prevalence has increased over time
1907 First reported resection of
complicated diverticulitis by Mayo
1925 5-10%
1969 35-50%
6. What exactly is a diverticulum?
Mostly Diverticulosis is actually not a true diverticulum
but rather a pseudo-diverticulum
True diverticulum contains all layers of the GI wall
(mucosa to serosa), eg congenital diverticula, traction diverticula.
Pseudo-diverticulum more like a local hernia
Mucosa-submucosa herniates through the muscle layer
(muscularis propria) and then is only covered by serosa
7. TYPES OF DIVERTICULA
1 Congenital. All three coats of the bowel are present in the
wall of the diverticulum, e.g. Meckel’s diverticulum.
2 Acquired. The wall of the diverticulum lacks a proper
muscular coat in most cases. Most alimentary diverticula are
thought to be acquired.
PULSION DIVERTICULA: develop at a site of weakness as a result
of chronic pressure against an obstruction.eg, Epiphrenic diverticula,
Zenker,s diverticula, most colonic diverticula
TRACTION DIVERTICULA:Fibrotic healing of the lymph nodes
exerts traction on the oesophageal wall and produces a focal
outpouching,eg Mid-oesophageal diverticula.
It is a true diverticula
8. Anatomic location of diverticuli
varies with the geographic location
“Westernized” nations (North America, Europe, Australia)
have predominantly left sided diverticulosis
95% diverticuli are in sigmoid colon
5% diverticuli are from pharynx to descending colon
Asia and Africa diverticulosis in general is rare and usually right
sided
Prevalence < 0.2%
10. Small Intestine diverticula
Most of these diverticula arise from the mesenteric side of the
Bowel.
Duodenal diverticula
1 Primary. Mostly occurring
in older patients on the inner
wallof the second and third
parts
2 Secondary. Diverticula of
the duodenal cap result from
longstanding
duodenal ulceration
12. Meckel’s Diverticulum
It is a true diverticula
Occurs in 2% of patients, are usually 2 inches (5 cm) in
length and are situated 2 feet (60 cm) from the ileocaecal
Valve
It should be sought when a normal appendix is found at
surgery for suspected appendicitis
It represents the patent intestinal end of the vitellointestinal duct
13. Colonic Diverticula
Classically Sigmoid
95% of all diverticuli
Rectal Sparing
The taeniae coalesce to form an
enveloping muscular layer in the
rectum. Much of the colonic wall is
therefore devoid of longitudinal
muscle and it is in these areas that
diverticula form.
15. Pathophysiology
Diverticuli develop in ‘weak’ regions of
the colon. Specifically, local hernias
develop where the vasa recta penetrate
the bowel wall
18. Diverticula do not arise randomly around the
circumference
of the colon
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21. Pathophysiology
Law of Laplace: P = kT / R
Pressure = K x Tension / Radius
Sigmoid colon has small diameter
resulting in highest pressure zone
22. 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
Compounded by the hyperelastosis, increase in
elastin deposition between the muscle cells in the
taenia and altered collagen structure seen in the
colon due to aging
23. Painter proposed a theory
of segmentation,postulating
that contraction of the colon
at haustral folds caused the
colon to act not as a
continuous tube but
as a series of discrete “little
bladders,” which led to
excessively high pressures
within each segment
24. 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
25. Lifestyle factors associated
with diverticular disease
Obesity associated with diverticulosis –
particularly in men under the age of 40
Lack of physical activity
26.
27. Uncomplicated diverticulosis
Considered ‘asymptomatic’
However, a significant minority of
patients will complain of cramping,
bloating, irregular BMs, narrow caliber
stools
IBS?
Recent studies demonstrate motility
abnormalities in pts with ‘symptomatic’
uncomplicated diverticulosis
28. Diverticular bleeding: Pathophysiology
Diverticulum herniates at site of
vasa recta
Over time, the vessel becomes
draped over the dome of the
diverticulum separated only by
mucosa
Over time, there is segmental
weakening of the artery
ruptures and bleeds
30. Diverticulitis
Diverticulitis = inflammation of diverticuli
Most common complication of
diverticulosis
Occurs in 10-25% of patients with
diverticulosis
31. Pathophysiology of
Diverticulitis
Micro or macroscopic perforation of the
diverticulum subclinical inflammation
to generalized peritonitis
Previously thought to be due to fecaliths
causing increased diverticular pressure;
this is really rare
32. Pathophysiology of
Diverticulitis
Erosion of diverticular wall from
increased intraluminal pressure
inflammation focal necrosis
perforation
Usually inflammation is mild and
microperforation is walled off by
pericolonic fat and mesentery
33. MANAGEMENT OF
DIVERTICULAR DISEASES
MANAGEMENT OF
PHARYNGOESOPHAGEAL
DIVERTICULA
MANAGEMENT OF SMALL
INTESTINAL DIVERTICULA
MANAGEMENT OF LARGE
INTESTINAL DIVERTICULA( COLONIC
DIVERTICULA)
34. MANAGEMENT OF PHARYNGOESOPHAGEAL
DIVERTICULA
DIAGNOSIS is confirmed by typical clinical presentations
like:
Dysphagia ,
Regurgitation ,
Aspiration,
Halitosis, excessive salivation, and a "lump in the throat" ,
INVESTIGATION:
Barium swallow and endoscopy
TREATMENT:
Endoscopically
Pouch excision
Diverticulopexy(pouch suspension)
Myotomy of cricopharyngeous
35. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA
ENDOSCOPIC PROCEDURE
A. Exposure of the esophagus and diverticulum is
gained with a diverticuloscope placed perorally.
B. The linear stapler is placed across the
cricopharyngeus muscle by placing a blade in
the esophagus and the diverticulum.
36. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA
OPEN PROCEDURE
The linear stapler is placed across the neck of the
diverticulum. Note that the bougie is in place before
transecting the diverticulum
37. MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA
Mid-oesophageal diverticula:
Are usually traction diverticula of no particular
consequence. The underlying motility disorder does
not usually require treatment.
Epiphrenic diverticula:
Large diverticula may be excised, and this should
be combined with a myotomy from the site of the
diverticulum down to the cardia to relieve
functional obstruction
38. Management 0f Duodenal diverticula
Mostly occurring in older patients
Usually asymptomatic.
Can cause problems locating the ampulla during endoscopic
retrograde cholangiopancreatography (ERCP).
If symptomatic resection and anastomosis can be done
39. Management 0f Jejunal diverticula
Clinically, they may be
symptomless
give rise to abdominal Pain
produce a malabsorption syndrome
present as an acute abdomen with acute
inflammation and occasionally perforation
TREATMENT:
Resection of the affected segment with end-to-end
anastomosis can be effective
40. Management of Meckel’s diverticulum
■ If a silent Meckel’s is found incidentally during the course
of an operation, it can be left alone provided it is wide
mouthed and not thickened
■ If ectopic gastric epithelium is present within the
diverticulum, it may be the source of gastrointestinal
bleeding, should be removed surgically
41. Management of Meckel’s diverticulum
Meckel’s diverticulectomy
Steps in the performance of Meckelian diverticulectomy
42. MANAGEMENT OF COLONIC DIVERTICULUM
Diagnosis is established by clasical history, physical examination
and investigation
Classic history: increasing OR constant,
LLQ abdominal pain over several days
prior to presentation with fever,
NATURE OF PAIN
Crescendo quality – each day is worse
Constant – not colicky
Fever occurs in 57-100% of cases
43. MANAGEMENT OF COLONIC DIVERTICULUM
Previous of episodes of similar pain
Associated symptoms
Nausea/vomiting 20-62%
Constipation 50%
Diarrhea 25-35%
Urinary symptoms (dysuria, urgency,
frequency) 10-15%
44. Contd.
Physical examination
Low grade fever
LLQ abdominal tenderness
Usually moderate with no peritoneal signs
Painful pseudo-mass in 20% of cases
Rebound tenderness suggests free
perforation and peritonitis
Labs : Mild leukocytosis
45% of patients will have a normal WBC
45. Contd.
Right sided diverticulitis tends to cause
RLQ abdominal pain; can be difficult to
distinguish from appendicitis
46. Contd.
Clinically, diagnosis can be made with
typical history and examination
Radiographic confirmation is often
performed
Rules out other causes of an acute
abdomen
Determines severity of the diverticulitis
47. Investigations
[Abdominal X-ray, barium
study]
Barium enemas show
diverticula as globular
outpouchings on X-ray film.
They typically have a signet-
ring appearance due to the
filling defect produced by
contained faecoliths.
www.mediscan.co.uk/cfm/resultssearch.cfm?box=...
49. Investigations
Diverticular strictures can simulate annular
carcinomas on barium X-ray as both have an ‘apple-
core’ appearance. Therefore an endoscope is also
needed for confirmation.
Diverticulosis- barium enema (colonoscopy)
Diverticulitis- CBC, CT scan
Diverticular mass/paracolic abscess- CT scan
50. Flexible sigmoidoscopy can visualise colonic
diverticula.
( Colonoscopy may also be able to visualise
affected segments)
52. Treatment of Diverticulitis
Complicated diverticulitis = Presence
perforation,
obstruction,
abscess, or fistula formation.
Uncomplicated diverticulitis = Absence
of the above complications
53. Treatment of Uncomplicated diverticulitis
Bowel rest or restriction
Clear liquids or NPO for 2-3 days
Then advance diet
Bulk purgatives
Antibiotics
Lifestyle modification : weight control
54. Treatment Uncomplicated diverticulitis
contd..
Monitoring clinical course
Pain should gradually improve several
days (decrescendo)
Normalization of temperature
Tolerance of po intake
IF symptoms deteriorate or fail to
improve with 3 days, then Surgery.
After resolution of attack high fiber
diet with supplemental fiber is advised
55. Treatment Uncomplicated diverticulitis
contd..
Follow-up: Colonoscopy in 4-6 weeks
Flexible sigmoidoscopy and BE reasonable
alternative
Purpose
Exclude neoplasm
Evaluate extent of the diverticulosis
56. Prognosis after resolution of
uncomplicated diverticulitis
30-40% of patients will remain
asymptomatic
30-40% of pts will have episodic
abdominal cramps without frank
diverticulitis
20-30% of pts will have a second attack
After a second attack elective
surgery
57. Prognosis after second attack
Second attack
Risk of recurrent attacks is high (>50%)
Some studies suggest a higher rate (60%) of
complications (abscess, fistulas, etc) in a second
attack and a higher mortality rate (2x compared to
initial attack)
Some argue elective surgery should be considered after a first
attack in
Young patients under 40-50 years of age
Immunosuppresed
59. Treatment Complicated
Diverticulitis: Abscess
HINCHEY CLASSIFICATION
Stage I Diverticulitis with associated pericolic
abscess
Stage II Diverticulitis associated with distant
abscess (retroperitoneal or pelvic)
Stage III Diverticulitis associated with purulent
peritonitis
Stage IV Diverticulitis associated with fecal
peritonitis
60. STAGE i and STAGE ii is suitably
managed with drainage and
antibiotics
STAGE iii and STAGE iv usually
requiring surgery
61. Treatment Complicated Diverticulitis: Abscess
Small <5 cm abscesses may resolve with
antibiotic therapy
Patient with larger abscesses or those who
falls to improve with antibiotics should
undergo CT guided percutaneous drainage
Colonic resection is indicated for those who
develop either recurrent diverticulitis or
another abscess
62. CT- GUIDED DRAINAGE OF
DIVERTICULAR ABSCESS:
Patient with abscess larger than or equal to 4 cm
can be managed with CT guided abscess drainage
followed by elective surgery after resolution.
63. Complicated Diverticulitis: Fistulas
Occurs in up to 80% of cases requiring
surgery
Major types
Colovesical fistula 65%
Colovaginal 25%
Coloenteric, colouterine 10%
65. Complicated Diverticulitis: Fistulas –
Symptoms-
Passage of gas and stool from the affected
organ
Colovesical fistula:
pneumaturia, dysuria, fecaluria
50% of patients can have diarrhoea and
passage of urine per rectum
66. Complicated Diverticulitis: Fistulas
Diagnosis
CT: thickened bladder with associated
colonic diverticuli adjacent and air in the
bladder
BE: direct visualization of fistula track only
occurs in 20-26% of cases
Flexible sigmoidoscopy is low yield (0-3%)
Some argue cystoscopy helpful
67. Complicated Diverticulitis: Treatment of colovesical Fistulas
Two Approach to treat colovesical fistula
1.Conservative: Without bowel resection by
closing the fistula and interposing omentum
between bowel and bladder.
2.Conventional: Pinching off the affected bowel
from the bladder, resect the sigmoid and
perform end to end anastomosis.
Bladder hole is left open and put urethral
catheter for free drainage
68. Treatment of Complicated Diverticulitis:With
generalised peritonitis
Surgery is principally directed to control sepsis in the
peritoneum and circulation.
Vigorous resuscitation and antibiotic therapy is still
warranted.
Opoid analgesia.
Oxygen therapy.
Urinary catheter to assess hourly urine out put
Resection of sigmoid colon and colorectal anastomosis
Primary resection and anastomosis after on table lavage
in selected case.
Hartman’s procedure : Resection of sigmoid colon with
formation of end colostomy when condition do not favour
primary anastomosis
69. Treatment of Complicated Diverticulitis:With
obstruction/stricture
Symptoms: pain,increasing constipation,
passage of ribbon like stools
However majority of patient presents with
classic symptoms of large bowel obstruction
Diagnosis is confirmed by ; patient’s history,
physical examinations and radiological
confirmation either by contrast enema or CT
with oral/rectal contrast
70. Treatment of Complicated Diverticulitis:With
obstruction/stricture
Conservative approach: Metallic stents to releive colonic
obstruction.
Endoluminal wall stents: shown to be safe and effective
in decompressing obstruction
Surgery: Hartman’s resection and resection with primary
anastomosis rarely with loop ostomy is the procedure of
choice.[Hartmann procedure is two stage procedure
includes-
Colostomy
Sigmoid resection
Rectal stump
3 months later colostomy takedown and colorectal
anastomosis
71. Diverticular bleeding:
Symptoms
Most only have symptoms of bloating
and diarrhea but no significant
abdominal pain
Painless hematochezia
Start – stop pattern; “water faucet”
Diverticulitis rarely causes bleeding
72. Diverticular bleeding:Management
Most common cause of brisk
hematochezia (30-50% of cases)
15% of patients with diverticulosis will
bleed
75% of diverticular bleeding stops
without need for intervention
Patients requiring less than 4 units of
PRBC/ day 99% will stop bleeding
Risk of rebleeding 14-38%
74. Diverticular bleeding:
Localization
Right colon is the source of diverticular
bleeding in 50-90% of patients
Possible reasons
Right colon diverticuli have wider necks
and domes exposing vasa recta over a
great length of injury
Thinner wall of the right colon
78. Diverticular bleeding: Surgery
Surgery
Segmental resection
If
site can be localized
Rebleeding rate of 0-14%
Subtotal colectomy
Rebleeding rate is 0%
High morbidity (37%)
High mortality (11-33%)