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Diverticular Disease Christopher Gross Gillian Lieberman, MD March 2008 Goals Definitions Epidemiology Anatomy Pathophysiology Symptoms Menu of Diagnostic Modalities Definitions Diverticulum– sac-like protrusion of the colonic wall that consists of mucosa, submucosa, serosa Diverticulosis– the presence of diverticula, often an incidental finding Diverticulitis– inflammation resulting from a perforation of a diverticulum Diverticular Hemorrhage– Diverticular bleeding usually not associated with diverticulitis Epidemiology Age: Affects <5% before 40yoÆ 30% at 60yoÆ 65% at 80yo 20% of those present with sxs Risk factors: “disease of Western Civilization” low fiber Æ constipation obesity, lack of physical activity NSAIDs smoking Anatomy Pseudodiverticula– Herniations of mucosa and submucosa covered by serosa where vasa rectae penetrate the circular muscle layer Between each side of the mesenteric taenia, and on one side of antimesenteric taeniae www.accesssurgery.com “Current Surgical Diagnosis and Treatment” http://www.meddean.luc.edu/ Pathophysiology 95% of diverticuli occur in the sigmoid In Asians, 70% present as R-sided pain Laplace’s law: (P=T/r), sigmoid has the smallest diameter and largest pressures Segmentation exaggeratedÆ increase in intralumenal P www.webmd.com Patient: KB 51 yo M who presents to ED with left lower abdominal pain and anorexia. History of Present Illness LLQ pain x 3wks; +distension and pressure PCP Rx Levofloxacin + Ciprofloxacin 2 wks prior No Nausea/Vomiting +Bowel Movements, no BRPRP, no diarrhea Afebrile, HR: 96, BP: 156/89 More information . . . PMH HTN Hyperlipidemia ?Sleep apnea ?GERD Hiatal Hernia Medications HCTZ 25mg QD Atenolol 25mg QD Physical Exam Significant findings: tender LLQ to palpation Distended, +rebound Labs Electrolytes, LFTs nl CBC: 16.0\___/336 /44.3\ Differential DDx: Differential Diagnosis Appendicitis, cholecystitis Ischemic colitis Colorectal CA Mesenteric infarction Cystitis Ovarian torsion IBD PID, endometriosis IBS Renal disease Incarcerated Hernia SBO, LBO Colorectal CA can have microperforations and become 2o infected Follow-up colonoscopy is recommended in 6-8wks in a suspicious CT. Clinical Presentation Clinical Presentation Incidence LLQ pain 93-100% Fever, chills 57-100% Leukocytosis 69-83% Nausea /Vomiting 20% Mass Constipation Diarrhea Urinary Sxs What should we order for our patient? Menu of Imaging Goals: establish Dx and demonstrate the extent and severity of diverticulitis; ?complications Menu: Barium Enema–largely outdated CT—test of choice US—in pregnancy Can be used in initial eval of lower abd pain, esp w/ females Will see hyperechogenicity surrounding bowel wall Companion Pt 1: Diverticulosis on Barium Enema Double contrast used to be gold standard Sensitivity: 82% Specificity: 81% Shows divertics, with sigmoid narrowing, extravasation (+) Provided info on presence and degree of diverticula ( - ) Cannot discern clinical relevance, missed Dx in 33% C/I in cases of suspected perforation and emergencies Luminal narrowing www.radiologychannel.net/diverticuliti CT: Test of Choice Triple contrast (IV, PO, rectal) now standard Sensitivity– 85-97% (+) Can quantify diverticulitis to direct management, see presence of complications CT based scoring system for diverticulitis Management Stage 0 Mural thickening and diverticulae Conservative Stage 1 Abscess/phlegmon <3cm in diam Conservative in low risk patients Stage 2 Abscess 5-15cm in diam CT-guided percutaneous drainage or Surgery Stage 3 Abscess beyond the confines of pelvis Surgery Stage 4 Fecal peritonitis Surgery Companion Pt 2: CT Manifestations of Diverticulitis Pericolic fat infiltration (98%) Thickened fascia, wall thickening >4mm (78.9%) Muscular Hypertrophy (26.3%) “Arrowhead” sign (23.7%) Other signs of complications Abscess (35%) Wall thickening Fat stranding Intramural sinus tract (with air or contrast) with thickened wall Fistulas Perforation Obstruction http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow228arr.jp Companion Pt 3 + 4: Percutaneous Drainage of Diverticular Abscess 5cm abscess, Stage 2 Pigtail catheter Thickened walls, sigmoid abscess http://www.emedicine.com/radio/images/336139‐367320‐6366.jpg Halligan, et al. “Imaging Diverticular Disease” • Percutaneous Drainage: Seldenger Technique with 12 French gauge locking pigtail catheter What does our patient’s CT show? Our Pt KB: Pelvic Fistula on Pelvic CT Small sinus tract 6cm Enteroenteric fistula PACS small sinus tract in pelvis communicating w/ rectosigmoid colon, dilated sigmoid Colocolonic fistula Companion Pt 5 + 6: Fistulas on CT and Abd Plain Film 2-10% of cases: Colovesical > colovaginal > coloenteric > colouteral Air, stool, oral contrast in bladder Air in bladder http://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html http://myweb.lsbu.ac.uk/dirt/museum/margaret/838-2454a-1480410.jpg Companion Pt 7: Perforation on Abd CT • Mortality for Stage III is 13% and Stage IV is 43% Extraluminal air Stollman, et al. “Diverticular Disease of the Colon” Treatment Recommendations CT scoring Management Stage 0 Conservative– Flagyl +/- Cipro; hospitalize if severe Stage 1 Conservative Stage 2 Drainage or Surgery Stage 3 Surgery (Sigmoid resection with 1o anastamosis) Stage 4 Surgery (Hartmann procedure) Elective Surgery: 6-8wks later One episode of complicated 2 confirmed episodes that require hospitalization Immunocompromised Our Pt KB: Hospital Course Hospital course of Amp, Levo, Flagyl Pt was scheduled for a hemicolectomy Found to have rectosigmoid stricture during ex-lap Low anterior resection (L hemicolectomy) with 1o anastamosis to the rectum Conclusion Diverticulosis vs. diverticulitis Initial Presentation of Diverticulitis Diagnostic Menu: know the CT manifestations and their associated treatments Thanks to: • Dr. Gillian Lieberman • Dr. Andrew Hines-Peralta • Dr. James Kang Works Cited Boulos PB “Complicated Diverticulitis” Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):649662. Review Buchanan GN, Kenefick NJ, Cohen CR. “Diverticulitis”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):635-47. Review Ferzoco LB, Raptopofhdfulos V, Silen W. “Acute diverticulitis”. N Engl J Med. 1998 May 21;338(21):1521-6. Review. Halligan S, Saunders B. “Imaging Diverticular Disease”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):595-610. Review Johnson CD, Baker M, Rice R, Silverman P, Thompson W. “Diagnosis of Acute Colonic Diverticulitis: Comparison of Barium Enema and CT” AJR 1987 March; 148: 541-546 Makela J, Vuolio S, Kiviniemi H, Laitinen S. “Natural history of diverticular disease: when to operate? “Dis Colon Rectum. 1998 Dec;41(12):1523-8. Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons. “Practice parameters for sigmoid diverticulitis”. Dis Colon Rectum 2006 Jul;49(7):939-44. Salzman H, Lillie D. “Diverticular Disease: Diagnosis and Treatment” American Family Physician. 2005 Oct 1; 72(7): 1229-1233 Shen SH, Chen JD, Tiu CM, Chou YH, Chang CY, Yu C. “Colonic diverticulitis diagnosed by computed tomography in the ED”. Am J Emerg Med 2002;20:552. Stollman N, Raskin J. “Diverticular Disease of the Colon”. The Lancet. 2004 Feb 21; 363: 631639
