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H.K. Oh M.D.
Department of General Surgery
Overview
r A J is an abnormal sac or pouch
protruding from the wall of a hollow organ.
ƥ Diverticula ; pouches
ƥ Diverticulosis ; condition of having diverticula
r |
is a common condition of Western
society and seems to be an unfortunate product of
the Industrial Revolution.
ƥ Decreased consumption of unprocessed cereals along
with the increased consumption of sugar and meat
r The formation of diverticula is also related to aging
ƥ Rare in individuals younger than the age of 30 years, but
at least two thirds of Americans will have developed
colonic diverticula by the age of 80.
^athogenesis
r Diverticula are actually herniations of
mucosa through the colon at sites of
penetration of the muscular wall by
arterioles
ƥ On the mesenteric side of the
antimesenteric teniae
r Sigmoid colon
ƥ The most common site (50%)
ƥ The smallest luminal diameter.
ƥ Low fiber diet
-> decreased colonic luminal content
-> high intraluminal pressures to propel the
feces forward
-> herniations of mucosa through the
anastomically weak points in the colonic wall
Diverticular bleeding
r The most common cause of hematochezia in
patients over the age of 60
ƥ 20% of patients with diverticulosis will have GI bleeding.
r Risk factor ; HT, Artherosclerosis, NSAID
r Usually self limited, but rebleeding risk (25%)
r Localization ; Colonoscopy, Angiography
r Surgery
ƥ Unstable hemodynamics, 6-unit bleed within 24 hr
ƥ Without localization ; Total colectomy
Diverticulitis
r Definition
ƥ Inflammation of a diverticulum, is related to the
retention of particulate material within the
diverticular sac and the formation of a fecalith
ƥ Actually an extraluminal pericolic infection caused
by the extravasation of feces through the
perforated diverticulum
r ^resentation
ƥ LLQ pain : may radiate to the suprapubic, groin,
back
ƥ Bowel habit change, Anorexia, Fever, Chill,
Urinary urgency
Diverticulitis
r ^hysical Findings
ƥ Dependent on the site of perforation, the amount
of contamination, and the presence or absence of
secondary infection of adjacent organs
ƥ Tenderness, Muscle guarding
ƥ Tender mass : phlegmon or abscess
ƥ Abdominal distension : ileus or obstruction
ƥ Tender fluctuant pelvic mass on rectal or vaginal
exam
Diverticulitis
r Diagnostic Tests
ƥ CT
The preferred test to confirm the suspected diagnosis
Location of infection, extent of inflammatory process,
presence and location of an abscess, secondary
complications
sigmoid diverticula, thickened colonic wall >4 mm, inflammation
within the pericolic fat the collection of contrast material or fluid
ƥ MRI, US
ƥ Water soluble contrast enema
Distinguish acute diverticulitis from perforated cancer
Risk of increasing the colonic pressure, extravasation
of feces through the perforated diverticulitis
Uncomplicated Diverticulitis
r Disease not associated with free intraperitoneal
perforation, fistula formation, or obstruction
r Nonoperative treatment
ƥ Bowel rest + Antibiotics ; 75% response
ƥ ë
or
and
J
; aerobic gram-negative rods and
anaerobic bacteria
ƥ The addition of to this regimen for
nonresponders ; enterococci
ƥ Single-agent therapy ; a third-generation penicillin such
as
ƥ The usual course of antibiotics is 7 to 10 days
Uncomplicated Diverticulitis
r Investigative studies
ƥ After the symptoms have subsided for at least 3 weeks
ƥ To establish the presence of diverticula and to exclude
cancer, which can mimic diverticulitis
ƥ Colonoscopy > Barium enema
r Recurrent disease
ƥ Second attack (<25%) -> Third attack (>50%)
ƥ Elective resection
After infection control ; usually 4 to 6 weeks after the episode
Laparoscopic resection ; growing trend
Immunocompromised patient : after single attack
Complicated Diverticulitis
r Hinchey classification
ƥ Stage I: ^ericolic or
mesenteric abscess