diverticulosis

1. Diverticular disease
Dr nawin kumar

2. • from the oesophagus to the rectosigmoid.
• Types
1. Congenital or true- 3 layers
2. Acquired or false- lacks a proper muscular coat

3. Small intestine
• Mesenteric side
• mucosal herniation through the point of entry
of blood vessels.

4. Duodenal diverticula
1. Primary-
– in older patients
– on the inner wall of the 2nd
n 3rd
parts
– found incidentally
– Usually asymptomatic
– problems locating the ampulla during
ERCP
1. Secondary
– Diverticula of the duodenal cap
– from long-standing duodenal
ulceration

5. Jejunal diverticula
• variable size and multiple
• common in patients with connective
tissue disorders
• Variable clinical presentation
1. Symptomless
2. abdominal pain
3. malabsorption syndrome-
• giving rise to anaemia, steatorrhoea,
hypoproteinaemia and vitamin B12
deficiency
• resection of the affected segment with
end-to-end anastomosis can be effective
1. acute abdomen
1. acute inflammation
2. Perforation.

6. Meckel’s diverticulum

7. Diverticulosis of colon
• outpouchings of the mucous membrane
• ‘false’ diverticula
• most commonly found in the descending and
sigmoid colon
• occur at weak points in the circular muscle
layer, where the blood vessels supply the
mucosa
• ‘Disease of The Western World’

8. • 60% over the age of 60 years
• Rare before 40

9. • Affects more to females

10. • most commonly found in the descending and
sigmoid colon
• Recum spared

11. • Rare in asian n african
• In Asia right-sided diverticular 2x

12. Saint’s triad
• Diverticulosis
• hiatus hernia
• gall stones

13. Aetiology
•Why colon is common site

14. Laplace law
The larger the vessel radius, the larger the
wall tension required to withstand a given
internal fluid pressure.

15. Aetiology
a weak colonic wall and High intraluminal pressure

16. weak colonic wall
• anatomic features intrinsic to the colon
– Longitudinal layer
• alterations in colonic wall with aging
• Genetically weak colonic wall
– defects in collagen consistency

17. High intraluminal pressure
• factors
–Physiological factors
• Motor dysfunction
• Lower colonic motility
• Colonic wall compliance
• Abnormal intraluminal pressures
–Dietary factors
• Diet low in fibre
• Chronic constipation

18. • Low-fibre diets distend the colon less than high-fibre
diets  high intramural pressures.
• Refined, low-fibre diets may also relate to muscle
spasm and muscular hypertrophy of the wall of the
sigmoid colon  high intraluminal pressures.

19. Aetiology
• Other factors
– Alcohol
– smoking
– Corticosteroid therapy

20. result
–herniation of the mucosa between the
taenia coli at sites of least resistance
(where blood vessels pierce the
circular muscle.)
– They tend to occur in rows between the strips of
longitudinal muscle, some-times partly covered by
appendices epiploicae

23. stages

24. diverticulosis
• 90%
• Asymptomatic
• Vague complain-
– Discomfort
– Fullness
– Bloating
– flatulance
• x ray- Saw tooth
appearance

25. spectrum of diverticular disease
• Diverticulitis
• Pericolic abscess
• Peritonitis
• Intestinal obstruction-
– In sigmoid -progressive fibrosis causing stenosis
– In small intestine - adherent loops to pericolitis
• Haemorrhage
• Fistula formation

26. Acute diverticulitis
• Faeces obstructs the neck of a diverticulum 
inflammation.

27. Acute diverticulitis
• ‘left-sided appendicitis’
• Change in bowel habit eg.constipation
• Bloody or purulent stool
• pain- colicky abdominal pain
• Tenderness- suprapubic, shifting to left iliac
fossa.
• Local signs of peritonitis
• Mass- tender, firm,nonmobile,resonant
• Fever, nausea and vomiting
• raised WCC

28. Aetiology
  "Thumbprinting" is a
radiological sign of
thickening of the colonic
wall (seen in left mid
quadrant on this plain
abdominal radiograph). It
occurs secondary to
submucosal haemorrhage
oedema from capillary
leakage. It can occur due to
anything that leads to
oedema of the bowel,
including diverticular
disease. www.emedicine.com/emerg/topic152.htm

29. Pathogenesis
• Thickening of the bowel wall in
the descending colon due to
bowel oedema can be seen in the
left lower quadrant on this CT
scan from a 62 yr old patient with
diverticulitis. The hypodense
(dark) spot in the bottom right of
the edematous colonic wall is an
abscess that is forming within the
bowel wall.
• This is a CT scan of sigmoid
diverticulitis in a 50yr old male
patient with a history of
diverticulosis and left lower
abdominal pain and tenderness.
www.emedicine.com/emerg/topic152.htm

30. Presentation
anatpat.unicamp.br/etgi.html

31. Presentation
• Patient presents with complications of
diverticular disease, acute - chronic.
• Acute diverticulitis - Faeces obstructs the neck
of a diverticulum  inflammation.
- Marked by suprapubic pain, shifting to left
iliac fossa.
- Fever, nausea and vomiting.
- ‘left-sided appendicitis’.
- Local signs of peritonitis, colicky abdominal
pain, raised WCC.
- Change in bowel habit eg.constipation.
• Perforated diverticulitis - Sudden onset of pain
with generalised peritonitis.
- Shocked
- Free gas on erect chest X-ray.
• Diverticular abscess - Perforated diverticulum
contained by anatomical structures  local
abscess.
- Abdominal mass on examination.
• Fistulas – most commonly with bladder.
- Colovesical fistula; cystitis, pneumaturia,
recurrent UTIs and faecal debris in the urine.
- Colovaginal fistula; faecal discharge per
vagina.
- Fistula with the small intestine  diarrhoea.
• Haemorrhage - Diverticula erode into adjacent
blood vessels.
- Sudden rush of bright or dark red blood per
rectum.
- Usually painless.

32. Investigations
•  [Abdominal X-ray, barium
study]
• Flexible sigmoidoscopy can
visualise colonic diverticula.
Colonoscopy may also be able to
visualise affected segments, but
the sigmoid colon is often rigid
and narrow in diverticular disease
which can make it hard for the
scope to progress.
• 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=...

33. 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- FBC, WCC, U+E,
chest x-ray, CT scan
• Diverticular mass/paracolic
abscess- CT scan
www.merck.com/mmhe/sec09/ch128/ch128c.html

34. Investigations
• Perforation- plain film of
abdomen, erect chest X-ray,
CT scan
• Obstruction- gastrograffin
or dilute barium enema,
colonoscopy to exclude
underlying malignancy.
Acute obstruction requires
a laparotomy to establish
the diagnosis of
diverticulitis.
• Fistula;
colovesical- MSU,
cystoscopy, barium enema
colovaginal- colposcopy,
flexible sigmoidoscopy
• Haemorrhage- colonoscopy,
selective angiography

35. Management
• Diverticulosis managed with dietary advice (increased fibre, increased
fluids).
• Uncomplicated symptomatic disease managed similarly, with a well-
balanced diet and smooth-muscle relaxants if necessary.
• Anti-spasmodics sometimes helpful.
• Avoid stimulants.
• Anastamoses for bowel resection must be made with rectum to avoid
recurrence
• Acute attacks of diverticulitis treated with cephalosporin and
metronidazole.
- Serious cases may require hospital admission for bowel rest, i.v fluids,
and antibiotic therapy.
• Diverticular abscesses initially managed as above.
- Paracolic abscesses can  purulent / faeculent peritonitis. Usually
drained surgically / under radiological guidance.
-Sometimes need resection and Hartmann’s procedure.

36. Management
• Perforated diverticulitis usually needs a laparotomy for diagnosis
confirmation.
- Also for washing-out contamination from abdominal cavity and resection
of sigmoid colon.
- Hartmann’s procedure with temporary left iliac fossa colostomy.
• Acute obstruction requires resection of the affected segment of colon
(bowel brought out as end colostomy).
• Fistula formation requires an elective colectomy and closure of the fistula.
• Haemorrhages usually stop spontaneously.
- Angiography and bowel resection may be needed.
• Post-inflammatory strictures may require elective resection of colon.
- If no acute inflammation or abscesses present, can perform a primary
anastamosis.
- Biopsy all colonic strictures to exclude underlying carcinoma.

37. Course & Prognosis
• 10-20% of patients experience complications,
mainly diverticulitis and lower GI bleeding.
• Conservative management of diverticular disease is preferred.
• Surgery reserved for major complications.
• In UK, surgery usually for cases of diverticular disease  fistulas,
obstruction, haemorrhage or recurrent inflammation.
• The Hinchey staging system used to reflect surgical outcome and risk of
secondary complications after managing the acute episode of diverticular
disease.
• 33% of patients with a first attack of diverticulitis will have a recurrence.
• 2-3 recurrences within 2 years are an indication for removal of the
affected colonic segment.
• The prognosis for diverticular disease is good with early detection and
treatment of complications.

38. • 80-85 % of patients with DD remain
asymptomatic
• 15-20 % of patients presenting
abdominal pain /complication

39. Complications
• Diverticulitis
• Peridiverticulitis
• Pericolic/Paracolic abscess
• Bleeding
• Intestinal obstruction

40. Complications
• Fistula
–Colovesical
–Coloenteric
–Colocutaneous
–Colovaginal

41. Diverticulitis
–Severe pain
–Recurrent episodes
–Guarding and rigidity
–Perforation –frank peritonitis
–Fecal peritonitis

42. Peridiverticulitis
• Fever
• Pain
• Inflammatory mass
• Organized perforated diverticuli

43. Peridiverticulitis
•Paracolic abscess
•Leads to fistula

44. Investigations
• Colonoscopy
• Barium enema
• CT scan
• Investigations (same as
LOWER GI BLEED)