Download DIVERTICULITIS

DIVERTICULITIS
Bernard M. Jaffe, MD
Professor of Surgery,
Emeritus
DIVERTICULA
• True- Involves All Layers of Bowel
• False- Involves a Portion of Bowel
Wall
• Pseudo- Herniation of Mucosa
Through Wall- No Muscularis
• Colonic Diverticula are False or
Pseudo- Diverticula
DIVERTICULOSIS
• Presence of Diverticula With No
Implication of Number or Location
• Rare <30 Years, 70% >80 Years
• Diets Low in Fiber, High in
Carbohydrates, Meats
DIVERTICULA
• Occur at Sites of Penetration of Wall
by Vessels
• Mesenteric Side of the Colon
• Between Mesenteric and Two Lateral
Taeniae
• Colonic Musculature Becomes
Hypertrophic
•
•
•
•
•
•
DIVERTICULA
50% Sigmoid
40% Ascending
Rare in Transverse
10% Throughout Colon
Do Not Occur in Rectum
Occur Due to Colonic Pressures as
High as 90mm Hg
•
•
•
•
•
•
•
•
DIVERTICULITIS
Misnomer- Should Be Peri-Diverticulitis
Occlusion of Neck of Diverticulum
↓
Distention With Secreted Mucus
↓
Venous Gangrene
↓
Perforation Into Mesocolon
SYMPTOMS
• Left Lower Quadrant Pain
•
Radiation to Suprapubic, Groin,
Back
• Alteration in Bowel Habits
•
Constipation or Diarrhea
• Fever, Chills, Urinary Urgency
• No Rectal Bleeding
PHYSICAL FINDINGS
• Depends on Site of Perforation
•
Amount of Contamination
•
Involvement of Adjacent
Organs
• Left Lower Quadrant Tenderness, Guarding
• Tender Left Lower Quadrant Mass
• Distention, Ileus
• Fluctuant Mass on Rectal, Vaginal Exam
CT SCAN
• Preferred Imaging Study
• Reveals Location of Infection
•
Extent of Process
•
Presence/Absence of Abcess
•
Secondary Complications
• Allows Percutaneous Drainage
HINCHEY CLASSIFICATION
• Estimates Severity of Disease
• Stage I. Pericolic or Mesenteric Abcess
•
II. Walled Off Pelvic Abcess
•
III. Generalized Purulent Peritonitis
•
IV. Generalized Feculent
Peritonitis
Based on Clinical and CT Information
UNCOMPLICATED DISEASE
• Treat With Antibiotics (Cipro and Flagyl)
• Avoid Morphine (Increases Intracolonic
Pressure)
• Avoid Colonoscopy, Barium enema
• Symptoms Should Resolve <48 Hours
• <25% Have Recurrent Attacks
• 6% Recovered Patients Need Operation
• Long-Term- High Fiber Diet
OPERATION
• Complicated Diverticulitis
• After Two or More Episodes
• Electively After Abcess Drainage
• Resection With Anastamosis
• Resection With Hartmann’s
Procedure and Colostomy
• Resect Only Involved Bowel, Not All
Diverticula
SIGMOID-URINARY FISTULAS
•
•
•
•
•
Pneumaturia, Fecaluria
Frequent Urinary Tract Infections
CT Scan- Air in Bladder
Cysto- Bullous Edema, Cystitis
Antibiotics, One Stage Colon Resection,
Possible Need for Repair of Bladder
PERITONITIS
• Two Causes• 1. “Free Perforation”- Colon to
Mesocolon to Free PeritoneumHinchey IV
• 2. Rupture of Abcess- Hinchey III
• Develop Acute Abdomen
• Often Free Air on Abdominal Film, CT
• Requires Emergency Operation
OBSTRUCTION
• Rarely Occurs
• Two Causes
• 1. Chronic Stricture Due to Progressive
Disease
• 2. Small Bowel Obstruction Due to
Adhesion of Intestine to
Inflammatory Process
• Both Need Operation