Diverticular Disease Of The Colon

Large bowel Anatomy recall

Diverticular Disease of the Colon Background Diverticula are sacklike protrusion of the colonic wall, varying in size from: a few millimeter to several centimeters True diverticular contain all layers of the colon wall and are believed to be congenital Remember

They are very uncommon in the colon

Diverticular Disease of the Colon Background False or pseudodiverticula represent herniations of the mucosa and submucosa through the circular muscle of the bowel wall The term diverticulosis simply indicates the presence of multiple diverticula of the colon

Unless otherwise stated, the term diverticula refers to the predominant lesion, namely, colonic pseudodiverticula

Diverticular Disease of the Colon Prevalence The prevalence of diverticula disease in the general population ranges between 35% and 50% as estimated by large autopsy and radiographic series

Prevalence directly correlates with age estimated to be less 5% at age 40 increasing to 30% by age 60, and as high as 65% by age 85

Diverticular Disease of the Colon Prevalence Geographically, diverticular disease is much more common in the Unites states and Western Europe than in other less industrialized regions such as: Africa South America and Asia

Diverticular Disease of the Colon Prevalence Although diet is thought to contribute significantly to the development of diverticular disease, the complete etiology is likely to involved other, as yet unrecognized, factors

For example, diverticular disease in Asian population is predominantly to the right colon, indistinct contrast to the left-sided predilection observed in Western civilization

Diverticular Disease of the Colon Prevalence Such variation in the anatomic distribution of diverticula among civilizations might suggest that factors other than diet alone

Diverticular Disease of the Colon Mechanical Factors Clinical studies within 30 years have implicated low fiber diets as a prominent etiologic factor in the development of diverticular disease

Diverticular Disease of the Colon Anatomic features Diverticula tend to develop at specific points in the circumference of the colon This localization is determined, in part, by the anatomic relationship between the colonic musculature and its nutrient blood supply

Diverticular Disease of the Colon Anatomic features Diverticula form at so-called weak points where the nutrient blood vessels (vasa recta) penetrate the circular muscle layer en route to the mucosa

Diverticular Disease of the Colon Mechanical Factors Diverticular therefore are usually located between the single mesenteric teniae and either of the two antimesenteric teniae

Diverticular Disease of the Colon Mechanical Factors In distribution of diverticular throughout the colon also tends to follow a pattern ►The overwhelming majority of diverticulosis will have involvement of the sigmoid colon (90% -95%) Conversely, only a small number of patients (2%-10%) will have disease confined to the right colon

►Solitary diverticula occur most commonly in the cecum

Diverticular Disease of the Colon

Cecum Ascending colon Transverse colon Descending colon Sigmoid colon

2 % 2 % 1 % 1 % 94%

Diverticular Disease of the Colon Natural history ► Most patients with diverticulosis remain asymptomatic throughout their life time

► It estimated that between 10% and 25% of patients eventually develop signs and symptoms of diverticulitis

► Another 15% present with diverticular hemorrhage

Diverticular Disease of the Colon Natural history ►As in most conditions, the prognosis of any one episode of:

* bleeding or * inflammation varies according to the ▼ 1) patient’s general health and 2) severity of the underlying disease process

Diverticular Disease of the Colon Natural history ►Patients with mild diverticulitis can be treated conservatively with excellent results

While patients with free intra-abdominal perforation of a diverticulum require emergent operation and can be expected to incur a 20% mortality

Diverticular Disease of the Colon Natural history After the first episode of diverticulitis, approximately one third of patients will sustain a second attack, usually within to 5 years

Another 30% to 40% will suffer from intermittent symptoms of: ▼ discomfort and crampy abdominal pain without requiring hospitalization

Diverticular Disease of the Colon Natural history The prognosis is worse after a second attack The morbidity and the mortality from the recurrent attack are also higher than that associated with an initial episode

Diverticular Disease of the Colon Natural history ► Complication such as: abscess formation or fistulization develop in approximately 20% of patients after a single attack of diverticulitis While the complication rate approaches 60% in patients who have had previous episodes

Diverticular Disease of the Colon Natural history Age: Because the diverticulosis is an acquired disease, the incidence of which clearly increases with age

Diverticular Disease of the Colon Complications of Diverticulosis Hemorrhage Diverticular disease is the most common cause of massive lower gastrointestinal bleeding in adults

Although, overall, colon carcinoma is the most common source of gastrointestinal blood loss, such bleeding, is usually small in volume, often being detected only as occult blood on chemical testing

Diverticular Disease of the Colon Hemorrhage Incidence and Etiology Bleeding can be expected to develop in 15% of patients with diverticulosis and before the use of: angiography and emergency colonoscopy diverticula were thought to account for up to 90% of significant lower intestinal hemorrhage

Diverticular Disease of the Colon Hemorrhage Incidence and Etiology With the advent of improved localization techniques, angiodysplastic lesions, also known as arteriovenous malformation have been implicated with increasing frequency as a cause of colonic bleeding

Diverticular Disease of the Colon Hemorrhage Incidence and Etiology massive colonic bleeding is due to: Diverticulosis: 30% to 50% Angiodysplasia: 20% to 30% The remaining causes include: colonic neoplasms inflammatory bowel disease ishemic colitis and rare congenital lesions

Hemorrhage Incidence and Etiology Diverticular hemorrhage arises from the right colon in 70% to 90% of patients Approximately 70% of patients with diverticular hemorrhage will stop bleeding spontaneously, often before presentation at the hospital

The risk of rebleeding is only 30%, but it increases to 50% after a second episode of hemorrhage

Diverticular Disease of the Colon Hemorrhage Clinical features Patients often described intermittent, sporadic passage of: bright red or marron blood per rectum

Fifty percent of patients will give a history of previous episode of colonic hemorrhage

Diverticular Disease of the Colon Hemorrhage Clinical features Usually: abdominal pain or discomfort is absent and physical examination is unremarkable

Diverticular Disease of the Colon Hemorrhage Clinical features ► 50% of patients with diverticular hemorrhage present with massive, exsanguinating hemorrhage

► Such patients demand: immediate resuscitation and therapeutic intravenous

Diverticular Disease of the Colon Hemorrhage Clinical features

►

The overwhelming majority of these patients are elderly, usually in their seventh or eighth decade

Consequently 70% of these patients have serious comorbid diseases

Diverticular Disease of the Colon Hemorrhage

Diagnosis The first step in the management of any patient with massive gastrointestinal hemorrhage is resuscitation ►Monitoring should be instituted rapidly, as for any

patient with the potential for hypovolemic shock

Diverticular Disease of the Colon Hemorrhage

Diagnosis The passage of a nasogastric tube helps exclude an upper gastrointestinal source of bleeding Resuscitation should commence before any further diagnostic maneuvers are undertaken

Hemorrhage Diagnosis ►All patients with massive lower gastrointestinal hemorrhage should undergo proctoscopy as soon as possible the main purpose of this examination is to exclude the rectum as the bleeding source Although difficult in the face of active hemorrhage, identification of bleeding from: hemorrhoids or other rectal lesions is extremely important

Diverticular Disease of the Colon Hemorrhage Diagnosis Seventy to 80% of patients will stop bleeding spontaneously, such patients should undergo elective evaluation

Continued massive bleeding in a hemodynamically unstable patients is an indication for emergent operation

Diverticular Disease of the Colon Hemorrhage Diagnosis However, in active bleeding patients who maintain relative hemodynamic stability, attempts at localization of the bleeding site should be made

Diverticular Disease of the Colon Hemorrhage Diagnosis ► Emergency selective mesenteric arteriography will successfully identify the site of hemorrhage in 40% to 60% of patients

Another alternative: ► Colonoscopy ► Radioisotop scan

Diverticular Disease of the Colon

Treatment Resuscitative measures: fluid blood transfusion and correction of coagulation abnormalities

► Vasopressin (is a potent vasoconstrictor) in intraarterial infusion

Diverticular Disease of the Colon Treatment ► Transcatheter embolization may be an alternative ► Surgery

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