Diverticular disease
Q: Define diverticular disease?
- Acquired herniations of colonic mucosa, protruding through the circular muscle at
the points where the blood vessels penetrate the colonic wall
*Cardinal word = herniation
Blood supply to the colon (A) and formation of the diverticulum (B). Note the passage of
the mucosal diverticulum through the muscle coat along the course of the artery.
Q: Tell me the terms use?
- Diverticulosis refer to an asymptomatic state
- Clinical diverticular disease in which the diverticula are causing symptoms
- Diverticulitis
Q: What is barium enema finding of diverticular disease?
- A concertina or saw-tooth appearance on barium enema
Barium enema showing sigmoid diverticular
disease ‘saw-teeth’ and diverticula
Q: List the complications of diverticular disease?
- Diverticulitis
o Recurrent periodic inflammation and pain – in some pts, these episodes
may be clinically silent.
- Pericolic abscess &/or Peritonitis
o Perforation leading to general peritonitis or local (pericolic) abscess
formation.
- Intestinal obstruction
o In the sigmoid as a result of progressive fibrosis causing stenosis;
o In the s/intestine caused by adherent loops of small intestine on the
pericolitis.
- Haemorrhage
o Diverticulitis may present with profuse colonic haemorrhage in 17% of
cases, often requiring blood transfusions.
- Fistula formation
o 5% of cases
o Types vesicocolic, vaginocolic, enterocolic, colocutaneous
o Vesicocolic being the most common
Q: What are the pathophysiologies of diverticulosis?
- Diverticulosis is associated with high intraluminal pressures.
- It is theorized that such pressures lead to segmentation
- Segmentation refers to a process whereby the colon effectively functions as a
series of separate compartments rather than a continuous tube.
- The high pressures that each compartment is capable of producing are directed
toward the colonic wall rather than as propulsive waves.
Q: How these high pressures cause diverticulosis?
- These pressures predispose to herniation of mucosa through the muscular defects
that exist where blood vessels penetrate to reach the submucosa and mucosa (vasa
recta brevia)
Q: Which part of colon is mostly involved?
- Sigmoid colon in 90% of cases
- Caecum can also be involved and, on occasion, the entire large bowel can be
affected.
Q: Why majority of cases involve sigmoid colon?
- Explained by the law of Laplace which states that the tension in the wall of a
hollow cylinder is proportional to its radius (r) times the pressure (P) within the
cylinder.
- Because of segmentation, the sigmoid generates pressures so high that the effect
of a smaller radius is overcome resulting in total tension in the wall of the sigmoid
colon being higher than the rest of the colon
Q: How high fibre intakes reduce risk of diverticulosis?
- A part of fiber’s protective effect is a result of stool bulking which maintains a
larger lumen, prevents segmenting contractions, and decreases high pressures
- The colon that copes with a large volume of feces has a wide diameter, will
generate a lower intraluminal pressure, and is less prone to produce diverticula.
- Pts with a diet high in fiber have a shorter colonic transit time, so the colon
absorbs water for less time & has to propel a less viscous fecal stream.
- Suppression of the call to stool favors drying of the feces and increasing
generation of pressure. The swiftly passed soft stool subjects the sigmoid colon to
less strain and does not favor the development of diverticula.
Q: What different between west and South-east Asia?
- Right-sided diverticular disease is twice as common as the left.
Q: Why taking NSAIDs have been linked to increased rates of complications related to
diverticular disease?
- Indirect mechanism
o Inhibition of cyclooxygenase resultant decreased prostaglandin
synthesis in the gut.
o Prostaglandins are important in the maintenance of mucosal blood flow
and an effective colonic mucosal barrier.
- Direct mechanism
o Through mucosal damage caused by NSAIDs which leads to increased
translocation of toxins and bacteria.
Q: What is the classification used for diverticulitis?
- Classification systems developed for acute diverticulitis look for degree of
contamination
- Hinchey is the most commonly used
Stage Severity Pain Systemic Investigation Management
I Pericolic LIF Possibly Delayed Bowel rest, IV
abscess or no change barium antibiotic, DVT
phlegmon enema,
prophylaxis and
endoscopy
fluids
II Pelvic or intra- Severe, Mild CT Percutaneous
abdominal fullness toxic drainage
abscess in LIF
III Non-faeculent Peritonitis Toxic CT Resuscitation +
peritonitis operation
IV Faeculent Peritonitis Severe Proceed to Resuscitation +
peritonitis toxicity, operation immediate
shock operation
Q: What are the indications for surgery?
Q: What are the principles of surgical management of diverticular disease?
- In elective cases with full bowel preparation, resection and primary anastomosis is
usually possible
- If there is obstruction, oedema, adhesions or perforation, Hartmann’s procedure is
usually the operation of choice
- In selected cases, resection and anastomosis after on-table lavage may be possible
- In cases of minimal peritoneal contamination, peritoneal lavage followed by
suture of a small perforation can also be performed
Q: How you treat diverticulosis?
- Primary management of asymptomatic diverticular disease is dietary manipulation
- Aim
o Increase the bulkiness of stool thus
Increasing lumen size
Decreasing transit time
Decreasing intraluminal pressures
Q: What are surgical options for diverticular disease?
- Primary resection with anastomosis with or without proximal diversion
- Resection with proximal colostomy, and oversewing of the rectal remnant
(Hartmann’s procedure) or mucous fistula (Mikulicz operation),
- Simple diversion with drainage of the affected segment
- Diversion with oversewing of the perforation site
- Subtotal colectomy (Rare)
Q: Is it true diverticulum or false diverticulum?
Q: When safe time for colonoscopy after diagnose perforated diverticular disease?
Diverticular disease (Prof SAM)
Radiograph of double contrast enema
Q: What is your finding?
- Presence of multiple diverticulum of right ascending colon
- There was no intraluminal lesion
- There was no filling defect within the lumen
Q: What is wrong in this film?
- I need to look the whole series
Q: Why?
- To look for any fistula or stricture
Endoscopic view – multiple diverticulosis
Q: When to operate?
- If extensive disease
- For total colectomy with ileorectal anastomosis
Bleeding diverticular disease
Q: If patient presented with PR bleeding with hypovolemic shock – what will you do?
- Resuscitation
- Emergency op
o Total colectomy with ileorectal anastomosis or end ileostomy
- Why? Increase survival
Q: Any role of colonoscopy or angiogram?
- No role because he already has hypovolemic shock
- Risk pt’s died at radiography/endoscopic suite
Q: If patient has history of PR bleeding but patient stable – what would you do?
- If fine option is wait
- If presence with cardiac dz(IHD,AF etc) elective surgery
Q: What will be the surgical option?
- Elective surgery Total colectomy with ileorectal anastomosis
Q: If patient has PR bleed but has diverticulitis?
- Try to exclude malignancy first. Possible bleeding d/t concurrent tumour
- Very rare incidence of diverticular bleeding with diverticulitis
Q: If patient has Hinchy I/II – what are the indication for op?
- Controversy
- Some
o No need surgery
o After another complication
o Operation later
