Lecture notes for medical students

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2. Format

3. Format
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.

5. Introduction & History.
• Diverticular disease (diverticulosis,
diverticulitis) is a general term that refers to
the presence of diverticula
• Diverticula small pouches in the large
intestinal (colonic) wall.
• These outpouchings arise when the inner
layers of the colon push through
weaknesses in the outer muscular layers.
• Notably, diverticulosis can occur anywhere
in the colon, but it is most common in the
left colon (descending or sigmoid colon).

6. Relevant Anatomy
•

7. Relevant Anatomy
•

8. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

9. Aetiology
• Idiopathic
• Increased pressure from constipation or increasing
abdominal girth in obesity.
• The classic high-fat and low-fiber diet of the
Western culture
• Many studies have demonstrated the significant
association between obesity and the risk of
developing diverticulitis

10. Pathophysiology

11. Pathophysiology
• Diverticular disease of the colon begins
as diverticulosis(colonic outpouchings)
• Diverticula usually occur adjacent to the vasa
recta, the small vessels that extend into the
submucosa, because these are the weakest areas of
the colonic wall. Therefore, diverticula usually
occur on the mesenteric side of the colon.
• Diverticulitis arises when diverticula become
inflamed or infected.

12. Pathophysiology
• The cause of diverticulitis is probably mechanical.
The stagnation of nonsterile inspissated fecal
material, termed a fecalith, within the diverticulum
may compromise the blood supply to the thin-
walled sac and render it susceptible to invasion by
colonic bacteria, causing inflammatory erosion of
the mucosal lining and perforation
• This sequence of events can involve perforation
into the colonic wall, with the formation of an
intramural abscess. However, perforation usually
occurs into the pericolic fat, leading to fibrinous
exudate, abscess formation, local adhesions,
or peritonitis..

13. Pathophysiology
• Most patients develop sealed-off abscesses or
contained sinus tracts and fistulas. Fistulas usually
involve adjacent structures, such as the bowel,
urinary bladder, vagina, and anterior abdominal
wall.
• Other potential complications include bowel
obstruction and peritonitis.

14. Pathology

15. Pathology
• Diverticulum :a blind tube leading from a cavity
or passage.
• True diverticula contain all the layers of the
gastrointestinal wall (mucosa, muscularis propria,
and adventitia) (eg, Meckel diverticulum).
• False diverticula, or pseudo-diverticula do not
contain the muscular layers or adventitia, only
involving the submucosa and mucosa.
• Diverticula can occur anywhere in the
gastrointestinal tract but are usually observed in
the colon.
• Sigmoid colon is the most commonly affected
site.

16. Pathology
• Diverticula found in the left colon (predominantly
in the sigmoid) are usually false diverticula, and
they are often seen in Western populations.
• Right-sided and cecal diverticula, however, are
more frequently true diverticula; these are usually
seen in people of Asian descent.
• Cecal diverticula are generally rare compared to
those found in the left colon.

17. Classification

18. Classification
Modified Hinchey classification
• Clinical staging by Hinchey's classification
is based on computed tomography findings
and directed toward selection of the proper
surgical procedure when diverticulitis is
complicated,

19. Classification
Modified Hinchey classification
1. Stage I : Phlegmon or localized pericolic
or mesenteric abscess
2. Stage II : Walled-off pelvic, intra-
abdominal, or retroperitoneal abscess
3. Stage III : Perforated diverticulitis causing
generalized purulent peritonitis
4. Stage IV : Rupture of diverticula into the
peritoneal cavity, with fecal contamination
causing generalized fecal peritonitis

20. Clinical Features

21. Clinical Features
• Demography
• Symptoms
• History
• Signs
• Prognosis
• Complications

22. Demography

23. Demography
• Diverticular disease occurs more frequently in
western countries
• North america, where approximately 50% of the
older adult population has diverticulosis,
• 0.5% prevalence in the developing nations of
africa and asia.
• Disease of older adults
• 20% of patients with diverticulitis are younger
than 50 years
• Continues to increase worldwide.

24. Demography
• In those younger than 50 years, diverticulitis is
more common in men; a slight female
preponderance exists between the ages of 50 and
70 years, and there is a marked female
preponderance in those older than 70 years.

25. Demography
• US 180/100,000 persons per year.
• The prevalence of diverticulitis has been
rising over the past several decades,
• Previously, it was believed that around
15%-20% of patients with diverticulosis
would develop diverticulitis; however, more
recent findings have shown the numbers to
be closer to 1%-4%

26. Symptoms

27. Symptoms
• The clinical presentation of diverticulitis
depends on
– the location of the affected diverticulum,
– the severity of the inflammatory process,
– and the presence of complications.

28. Symptoms
• Abdominal pain (most commonly in the left
lower quadrant)
• Nausea
• Vomiting
• Constipation or obstipation
• Fever
• Flatulence
• Bloating
Like left sided appendicitis

29. Signs

30. Signs
• Localized abdominal tenderness
• Abdominal distention
• Tympanic abdomen to percussion
• A tender mass (abscess formation)
• Hypo- or hyperactive bowel sounds
• Absent bowel sounds (perforation)
• Generalized abdominal pain with rebound
and guarding (perforation)
• Urinary tract findings

31. Signs
Urinary tract finding
(colovesicular/colovaginal fistula)
• Suprapubic, flank, costovertebral
tenderness;
• Pneumaturia (air in urine);
• Fecaluria (stool in urine);
• Purulent vaginal discharge

32. Prognosis

33. Prognosis
• The prognosis depends on
• Age of patient
• the severity of the illness
• the presence of complications
• the presence of any coexisting medical problems.
• Younger patients with diverticulitis may have
more severe disease, possibly due to a delay in the
diagnosis and treatment.
• Immunosuppressed patients have significantly
higher morbidity and mortality due to sigmoid
diverticulitis.

34. Prognosis:Morbidity/mortality
• Of the patients who have diverticulosis, 80%-85%
remain asymptomatic
• After a first occurrence of acute diverticulitis, the
5-year recurrence rate is 20%
• The mortality from complications in patients with
recurrent disease 1%.

35. Complications

36. Complications
• Fistulas usually involve adjacent structures,
such as the bowel, urinary bladder, vagina,
and anterior abdominal wall.
• Bowel obstruction: Recurrent attacks of
diverticulitis can result in the formation of
scar tissue, leading to narrowing and
obstruction of the colonic lumen.
• Bowel perforation
• Generalized peritonitis
• Sepsis.

37. Investigations

38. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germline Testing and Molecular Analysis
• Diagnostic Laparotomy.

39. Investigations
• Laboratory Studies
– Routine
• leukocytosis and a left shift
• Urinalysis may reveal red or white blood cells

40. Diagnostic Studies

41. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

42. Imaging Studies

43. Imaging Studies
CT the best imaging method to confirm the
diagnosis.
• Pericolic fat stranding due to inflammation
• Colonic diverticula
• Bowel wall thickening
• Soft-tissue inflammatory masses
• Phlegmon
• Abscesses

44. Imaging Studies

45. Imaging Studies
• Contrast enema, using water-soluble
medium, may be an option in mild-to-
moderate uncomplicated cases of
diverticulitis.
• A plain abdominal radiographic series with
supine and upright films can demonstrate
bowel obstruction or ileus; the presence of
free air can indicate bowel perforation.

46. Differential Diagnosis

47. Differential Diagnosis
• Right-sided diverticulitis of the cecum or
ascending colon may present with right
lower quadrant pain, which may be
confused for acute appendicitis.
• irritable bowel syndrome.
• Diverticulitis in the transverse colon may
mimic peptic ulcer disease, pancreatitis,
or cholecystitis
• Retroperitoneal involvement may present
similarly to renal disease.

48. Differential Diagnosis
• In women, lower quadrant pain may be
difficult to distinguish from a gynecologic
process.
• A small percentage of patients may
complain of urinary symptoms, such as
dysuria, urgency, and frequency, due to the
inflammation adjacent to urinary tract
structures.
• Ca Coon

49. Differential Diagnosis
• More severe diverticulitis is often
accompanied by anorexia, nausea, and
vomiting.
• Typically, the pain is localized, severe, and
present for several days prior to
presentation.
• An altered bowel habit, especially
constipation, is reported by most patients.

50. Management

51. Management
The management of patients with
diverticulitis depends on
1. presentation severity
2. presence of complications
3. comorbid conditions.
• Uncomplicated diverticulitis can be managed
medically and in an ambulatory setting.
• Complicated disease requires a more aggressive
approach that can often require urgent or elective
surgery, and treatments that are specific to the
complication itself (ie, abscess drainage)

52. Non Operative Therapy

53. Non Operative Therapy
• Antibiotics have been the mainstay of
therapy for most patients with acute
diverticulitis, but more recently, their
necessity has been questioned, especially in
mild, uncomplicated disease

54. Outpatient treatment

55. Outpatient treatment
Mild diverticulitis, hinchey stage 0 and ia
• Clear liquid diet for 2-3 days; advancement
to low fiber as tolerated
• 7-10 days of oral (PO) broad-spectrum
antimicrobial therapy on a case-by case
basis
• Acetaminophen and antispasmodics for pain

56. Antibiotic Regimes

57. Antibiotic Regimes
• Ciprofloxacin plus metronidazole
• Trimethoprim-sulfamethoxazole plus
metronidazole
• Amoxicillin-clavulanate
• Moxifloxacin (for patients intolerant of both
metronidazole and beta-lactam agents)

58. Indications for hospital admission
•

59. Indications for hospital admission
• Evidence of severe diverticulitis (ie,
systemic signs of infection or peritonitis)
• Inability to tolerate oral hydration
• Failure of outpatient therapy (ie, persistent
or increasing fever, pain, or leukocytosis
after 2-3 days) [8]
• Immune-compromise or significant
comorbidities
• Pain severe enough to require parenteral
narcotic analgesia

60. Modified Hinchey stages II-IV

61. Modified Hinchey stages II-IV
• Hospitalization
• Nothing by mouth
• IV antibiotics
• Percutaneous abscess drainage
• Surgical consultation and elective procedure
for patients in stage II
• Urgent surgical evaluation and resection for
those in stage III and IV.

62. Stages II-IV:Antibiotics

63. Stages II-IV:Antibiotics
• Piperacillin/tazobactam,
• Ticarcillin/clavulanic acid, or ertapenem.
• Meropenem,
• Imipenem-cilastatin,
• Doripenem.

64. Multiple-drug regimens

65. Multiple-drug regimens
• Metronidazole and a third-generation
cephalosporin or a fluoroquinolone, such as
ceftriaxone, cefotaxime, ciprofloxacin, or
levofloxacin.
• Multiple-drug regimens include cefepime
plus metronidazole
• Ceftazime plus metronidazole.

66. Pain management
•

67. Pain management
• Morphine is preferred, despite theoretical
risk of affecting bowel tone and sphincters.
• Meperidine is associated with adverse
effects.
• Nonsteroidal anti-inflammatory drugs and
corticosteroids have been associated with a
greater risk of colonic perforation.
• Acetaminophen and antispasmodics such as
dicyclomine are first-line agents for
managing pain and cramping in mild to
moderate disease.

68. Operative Therapy:indications

69. Operative Therapy:indications
• Free-air perforation with fecal peritonitis
• Suppurative peritonitis secondary to a
ruptured abscess
• Uncontrolled sepsis
• Abdominal or pelvic abscess (unless CT
scan-guided aspiration is possible)
• Fistula formation
• Intestinal obstruction
• Failing medical therapy
• Immunocompromised status

70. Operative Therapy

71. Operative Therapy
• Emergency colectomy is performed when
severe complications arise or when the
patient's condition does not respond to
medical treatment.
• Elective resection of the involved bowel
segment after three episodes of
uncomplicated diverticulitis
• Earlier resection for younger patients with
diverticulitis as well as for patients who are
immunocompromised has been proposed.

72. Operative Therapy
• Percutaneous drainage of a diverticular
abscess.
• Patients who have been successfully treated
for acute diverticulitis should be reassessed
in 6-8 weeks. Those who are symptom free
at that time should undergo colonoscopy to
rule out malignancy,

73. Futuristic

74. Futuristic
• It has been postulated that diverticulitis may
also result from alterations in immune
responses and in the intestinal bacteria, or
gut microbiome.
• Investigators hope to isolate and grow
bacteria from stool samples of individuals
with asymptomatic diverticulosis and those
with acute diverticulitis.

75. Futuristic
• Should these bacterial populations
statistically differ, it may help clinicians to
understand which patients are at a greater
risk of developing diverticulitis.
• It may also allow the treatment of such
changes in microbiota and the prevention of
complicated disease.

76. Prevention

77. Prevention
• High-fiber diet and a vegetarian diet
• daily rigorous exercise
• Mesalamine, rifaximin, and probiotics are
not recommended to prevent recurrence.

78. Guidelines

79. Guidelines
• 2006 American Society of Colon and Rectal
Surgeons (ASCRS) practice parameters
• 2015 American Gastroenterological
Association (AGA) guidelines

80. Take home messages

81. Take home messages
• Diverticulosis is a condition of Western
elderly.
• Diverticulitis presents mostly same as left
sided appendicitis.
• CT abdomen is mainstay of diagnosis
• Mild cases- conservative tt
• Percutaneous abscess drainage.
• Colectomy – emergency or elective.
• Fibre rich diet for prevention.

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