Diverticular Disease

DR. RAJNISH
DR. ALTAMASH
Nomenclature

 Diverticulum = sac-like protrusion of the

gut wall

 Diverticulosis = describes the presence

of diverticuli

 Diverticulitis = inflammation of diverticuli

Epidemiology

 Before the 20th century, diverticular

disease was rare

 Prevalence has increased over time

 1907 First reported resection of
complicated diverticulitis by Mayo
 1925 5-10%
 1969 35-50%
Epidemiology

 Increases with age

 Age 40 <5%

 Age 60 30%

 Age 85 65%
Epidemiology
 Gender prevalence depends on age

 M>>F Age less than 40

 M>F Age 40-50

 F>M Ages 50-70

 F>>M Ages > 70

 What exactly is a diverticulum?

Mostly Diverticulosis is actually not a true diverticulum

but rather a pseudo-diverticulum
 True diverticulum contains all layers of the GI wall
(mucosa to serosa), eg congenital diverticula, traction diverticula.

Pseudo-diverticulum more like a local hernia

Mucosa-submucosa herniates through the muscle layer
(muscularis propria) and then is only covered by serosa
 TYPES OF DIVERTICULA
1 Congenital. All three coats of the bowel are present in the
wall of the diverticulum, e.g. Meckel’s diverticulum.
2 Acquired. The wall of the diverticulum lacks a proper
muscular coat in most cases. Most alimentary diverticula are
thought to be acquired.

PULSION DIVERTICULA: develop at a site of weakness as a result

of chronic pressure against an obstruction.eg, Epiphrenic diverticula,
Zenker,s diverticula, most colonic diverticula

TRACTION DIVERTICULA:Fibrotic healing of the lymph nodes

exerts traction on the oesophageal wall and produces a focal
outpouching,eg Mid-oesophageal diverticula.
It is a true diverticula
 Anatomic location of diverticuli
varies with the geographic location
 “Westernized” nations (North America, Europe, Australia)
have predominantly left sided diverticulosis
95% diverticuli are in sigmoid colon
5% diverticuli are from pharynx to descending colon
 Asia and Africa diverticulosis in general is rare and usually right
sided
 Prevalence < 0.2%
 OESOPHAGEAL DIVERTICULA

1.Pharyngoe
sophageal

2.Midesopha
geal

3.epiphrenic
 Small Intestine diverticula
Most of these diverticula arise from the mesenteric side of the
Bowel.

Duodenal diverticula

1 Primary. Mostly occurring

in older patients on the inner
wallof the second and third
parts

2 Secondary. Diverticula of
the duodenal cap result from
longstanding
duodenal ulceration
Jejunal And Meckel’s
Diverticulum
 Meckel’s Diverticulum
 It is a true diverticula

Occurs in 2% of patients, are usually 2 inches (5 cm) in

length and are situated 2 feet (60 cm) from the ileocaecal
Valve

 It should be sought when a normal appendix is found at

surgery for suspected appendicitis

It represents the patent intestinal end of the vitellointestinal duct

 Colonic Diverticula

Classically Sigmoid
95% of all diverticuli

Rectal Sparing
The taeniae coalesce to form an
enveloping muscular layer in the
rectum. Much of the colonic wall is
therefore devoid of longitudinal
muscle and it is in these areas that
diverticula form.
Diverticular Disease
Pathophysiology

 Diverticuli develop in ‘weak’ regions of

the colon. Specifically, local hernias
develop where the vasa recta penetrate
the bowel wall
 Mucosa

Submucosa

Muscularis Vasa recta

Serosa
Diverticula do not arise randomly around the
circumference
of the colon
T
h
e
y

o
r
i
g
i
n
a
t
e

i
n

f
o
u
r

d
i
s
t
i
n
c
t

r
o
w
s

t
h
a
t

c
o
r
r
e
s
p
o
n
d

t
o

t
h
e

f
o
u
r

s
i
t
e
s

o
f

p
e
n
e
t
r
a
Diverticular Disease-macroscopic
ENDOSCOPIC APPEARANCE OF
COLONIC DIVERTICULA
Pathophysiology

 Law of Laplace: P = kT / R

 Pressure = K x Tension / Radius

 Sigmoid colon has small diameter

resulting in highest pressure zone
Pathophysiology
 Segmentation = motility process in which the
segmental muscular contractions separate the
lumen into chambers

 Segmentation  increased intraluminal pressure

 mucosal herniation  Diverticulosis
May explain why high fiber prevents diverticuli by creating a larger
diameter colon and less vigorous segmentation

 Compounded by the hyperelastosis, increase in

elastin deposition between the muscle cells in the
taenia and altered collagen structure seen in the
colon due to aging
Painter proposed a theory
of segmentation,postulating
that contraction of the colon
at haustral folds caused the
colon to act not as a
continuous tube but
as a series of discrete “little
bladders,” which led to
excessively high pressures
within each segment
Lifestyle factors associated
with diverticular disease
 Low fiber  diverticular disease

 Not absolutely proven in all studies but

strongly suggested

 Western diet is low in fiber with high

prevalence of diverticulosis

 In contrast, African diet is high in fiber with

a low prevalence of diverticulosis
Lifestyle factors associated
with diverticular disease
 Obesity associated with diverticulosis –
particularly in men under the age of 40

 Lack of physical activity

Uncomplicated diverticulosis
 Considered ‘asymptomatic’

 However, a significant minority of

patients will complain of cramping,
bloating, irregular BMs, narrow caliber
stools
 IBS?
 Recent studies demonstrate motility
abnormalities in pts with ‘symptomatic’
uncomplicated diverticulosis
 Diverticular bleeding: Pathophysiology

 Diverticulum herniates at site of

vasa recta
 Over time, the vessel becomes
draped over the dome of the
diverticulum separated only by
mucosa
 Over time, there is segmental
weakening of the artery 
ruptures and bleeds
Diverticular bleeding: Pathophysiology
Diverticulitis

 Diverticulitis = inflammation of diverticuli

 Most common complication of

diverticulosis

 Occurs in 10-25% of patients with

diverticulosis
Pathophysiology of
Diverticulitis
 Micro or macroscopic perforation of the
diverticulum  subclinical inflammation
to generalized peritonitis
 Previously thought to be due to fecaliths
causing increased diverticular pressure;
this is really rare
Pathophysiology of
Diverticulitis
 Erosion of diverticular wall from
increased intraluminal pressure 
inflammation  focal necrosis 
perforation

 Usually inflammation is mild and

microperforation is walled off by
pericolonic fat and mesentery
 MANAGEMENT OF
DIVERTICULAR DISEASES
MANAGEMENT OF
PHARYNGOESOPHAGEAL
DIVERTICULA

MANAGEMENT OF SMALL
INTESTINAL DIVERTICULA

MANAGEMENT OF LARGE
INTESTINAL DIVERTICULA( COLONIC
DIVERTICULA)
MANAGEMENT OF PHARYNGOESOPHAGEAL
DIVERTICULA
DIAGNOSIS is confirmed by typical clinical presentations
like:
 Dysphagia ,
Regurgitation ,
 Aspiration,
 Halitosis, excessive salivation, and a "lump in the throat" ,

INVESTIGATION:
 Barium swallow and endoscopy

TREATMENT:
Endoscopically
Pouch excision
Diverticulopexy(pouch suspension)
Myotomy of cricopharyngeous
MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

ENDOSCOPIC PROCEDURE
A. Exposure of the esophagus and diverticulum is
gained with a diverticuloscope placed perorally.
B. The linear stapler is placed across the
cricopharyngeus muscle by placing a blade in
the esophagus and the diverticulum.
MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

OPEN PROCEDURE
The linear stapler is placed across the neck of the
diverticulum. Note that the bougie is in place before
transecting the diverticulum
MANAGEMENT OF PHARYNGOESOPHAGEAL DIVERTICULA

Mid-oesophageal diverticula:
Are usually traction diverticula of no particular
consequence. The underlying motility disorder does
not usually require treatment.

Epiphrenic diverticula:
Large diverticula may be excised, and this should
be combined with a myotomy from the site of the
diverticulum down to the cardia to relieve
functional obstruction
 Management 0f Duodenal diverticula

Mostly occurring in older patients

 Usually asymptomatic.

 Can cause problems locating the ampulla during endoscopic

retrograde cholangiopancreatography (ERCP).

If symptomatic resection and anastomosis can be done

 Management 0f Jejunal diverticula

Clinically, they may be

 symptomless
 give rise to abdominal Pain
 produce a malabsorption syndrome
 present as an acute abdomen with acute
inflammation and occasionally perforation
TREATMENT:
Resection of the affected segment with end-to-end
anastomosis can be effective
Management of Meckel’s diverticulum

■ If a silent Meckel’s is found incidentally during the course

of an operation, it can be left alone provided it is wide
mouthed and not thickened

■ If ectopic gastric epithelium is present within the

diverticulum, it may be the source of gastrointestinal
bleeding, should be removed surgically
Management of Meckel’s diverticulum
Meckel’s diverticulectomy
Steps in the performance of Meckelian diverticulectomy
MANAGEMENT OF COLONIC DIVERTICULUM

Diagnosis is established by clasical history, physical examination

and investigation

 Classic history: increasing OR constant,

LLQ abdominal pain over several days
prior to presentation with fever,
NATURE OF PAIN
 Crescendo quality – each day is worse
 Constant – not colicky
 Fever occurs in 57-100% of cases
MANAGEMENT OF COLONIC DIVERTICULUM

 Previous of episodes of similar pain

 Associated symptoms
 Nausea/vomiting 20-62%
 Constipation 50%
 Diarrhea 25-35%
 Urinary symptoms (dysuria, urgency,
frequency) 10-15%
Contd.
 Physical examination
 Low grade fever
 LLQ abdominal tenderness
 Usually moderate with no peritoneal signs
 Painful pseudo-mass in 20% of cases
 Rebound tenderness suggests free
perforation and peritonitis

 Labs : Mild leukocytosis

 45% of patients will have a normal WBC
Contd.

 Right sided diverticulitis tends to cause

RLQ abdominal pain; can be difficult to
distinguish from appendicitis
Contd.

 Clinically, diagnosis can be made with

typical history and examination

 Radiographic confirmation is often

performed
 Rules out other causes of an acute
abdomen
 Determines severity of the diverticulitis
 Investigations

  [Abdominal X-ray, barium

study]

 Barium enemas show

diverticula as globular
outpouchings on X-ray film.
They typically have a signet-
ring appearance due to the
filling defect produced by
contained faecoliths.

www.mediscan.co.uk/cfm/resultssearch.cfm?box=...
DOUBLE CONTRAST BARIUM STUDY
 Investigations
Diverticular strictures can simulate annular
carcinomas on barium X-ray as both have an ‘apple-
core’ appearance. Therefore an endoscope is also
needed for confirmation.

Diverticulosis- barium enema (colonoscopy)

Diverticulitis- CBC, CT scan

Diverticular mass/paracolic abscess- CT scan

Flexible sigmoidoscopy can visualise colonic
diverticula.
( Colonoscopy may also be able to visualise
affected segments)
CT SCAN FINDINGS
Treatment of Diverticulitis

 Complicated diverticulitis = Presence

perforation,
obstruction,
abscess, or fistula formation.

 Uncomplicated diverticulitis = Absence

of the above complications
Treatment of Uncomplicated diverticulitis

 Bowel rest or restriction

 Clear liquids or NPO for 2-3 days
 Then advance diet
 Bulk purgatives

 Antibiotics
 Lifestyle modification : weight control
Treatment Uncomplicated diverticulitis
contd..

 Monitoring clinical course

 Pain should gradually improve several
days (decrescendo)
 Normalization of temperature
 Tolerance of po intake
 IF symptoms deteriorate or fail to
improve with 3 days, then Surgery.
 After resolution of attack  high fiber
diet with supplemental fiber is advised
Treatment Uncomplicated diverticulitis
contd..

 Follow-up: Colonoscopy in 4-6 weeks

 Flexible sigmoidoscopy and BE reasonable

alternative

 Purpose
 Exclude neoplasm
 Evaluate extent of the diverticulosis
Prognosis after resolution of
uncomplicated diverticulitis

 30-40% of patients will remain

asymptomatic
 30-40% of pts will have episodic
abdominal cramps without frank
diverticulitis
 20-30% of pts will have a second attack
 After a second attack  elective
surgery
Prognosis after second attack

 Second attack
 Risk of recurrent attacks is high (>50%)

 Some studies suggest a higher rate (60%) of

complications (abscess, fistulas, etc) in a second
attack and a higher mortality rate (2x compared to
initial attack)

Some argue elective surgery should be considered after a first

attack in
 Young patients under 40-50 years of age
 Immunosuppresed
Treatment of complicated diverticulitis
Treatment Complicated
Diverticulitis: Abscess
HINCHEY CLASSIFICATION
Stage I Diverticulitis with associated pericolic
abscess
Stage II Diverticulitis associated with distant
abscess (retroperitoneal or pelvic)
Stage III Diverticulitis associated with purulent
peritonitis
Stage IV Diverticulitis associated with fecal
peritonitis
STAGE i and STAGE ii is suitably
managed with drainage and
antibiotics

STAGE iii and STAGE iv usually

requiring surgery
Treatment Complicated Diverticulitis: Abscess

Small <5 cm abscesses may resolve with

antibiotic therapy

Patient with larger abscesses or those who

falls to improve with antibiotics should
undergo CT guided percutaneous drainage

Colonic resection is indicated for those who

develop either recurrent diverticulitis or
another abscess
 CT- GUIDED DRAINAGE OF
DIVERTICULAR ABSCESS:

 Patient with abscess larger than or equal to 4 cm

can be managed with CT guided abscess drainage
followed by elective surgery after resolution.
Complicated Diverticulitis: Fistulas

 Occurs in up to 80% of cases requiring

surgery
 Major types
 Colovesical fistula 65%
 Colovaginal 25%
 Coloenteric, colouterine 10%
COLOVESICAL, COLOUTERINE AND COLOVAGINAL FISTULAE
Complicated Diverticulitis: Fistulas –
Symptoms-

 Passage of gas and stool from the affected

organ

 Colovesical fistula:
 pneumaturia, dysuria, fecaluria

 50% of patients can have diarrhoea and

passage of urine per rectum
Complicated Diverticulitis: Fistulas

 Diagnosis
 CT: thickened bladder with associated
colonic diverticuli adjacent and air in the
bladder
 BE: direct visualization of fistula track only
occurs in 20-26% of cases
 Flexible sigmoidoscopy is low yield (0-3%)
 Some argue cystoscopy helpful
Complicated Diverticulitis: Treatment of colovesical Fistulas

 Two Approach to treat colovesical fistula

1.Conservative: Without bowel resection by
closing the fistula and interposing omentum
between bowel and bladder.
2.Conventional: Pinching off the affected bowel
from the bladder, resect the sigmoid and
perform end to end anastomosis.
 Bladder hole is left open and put urethral
catheter for free drainage
Treatment of Complicated Diverticulitis:With
generalised peritonitis
 Surgery is principally directed to control sepsis in the
peritoneum and circulation.
 Vigorous resuscitation and antibiotic therapy is still
warranted.
 Opoid analgesia.
 Oxygen therapy.
 Urinary catheter to assess hourly urine out put
 Resection of sigmoid colon and colorectal anastomosis
 Primary resection and anastomosis after on table lavage
in selected case.
 Hartman’s procedure : Resection of sigmoid colon with
formation of end colostomy when condition do not favour
primary anastomosis
Treatment of Complicated Diverticulitis:With
obstruction/stricture

 Symptoms: pain,increasing constipation,

passage of ribbon like stools
 However majority of patient presents with
classic symptoms of large bowel obstruction
 Diagnosis is confirmed by ; patient’s history,
physical examinations and radiological
confirmation either by contrast enema or CT
with oral/rectal contrast
 Treatment of Complicated Diverticulitis:With
obstruction/stricture
 Conservative approach: Metallic stents to releive colonic
obstruction.
 Endoluminal wall stents: shown to be safe and effective
in decompressing obstruction
 Surgery: Hartman’s resection and resection with primary
anastomosis rarely with loop ostomy is the procedure of
choice.[Hartmann procedure is two stage procedure
includes-
 Colostomy

 Sigmoid resection

 Rectal stump

 3 months later  colostomy takedown and colorectal

anastomosis
Diverticular bleeding:
Symptoms
 Most only have symptoms of bloating
and diarrhea but no significant
abdominal pain
 Painless hematochezia
 Start – stop pattern; “water faucet”

 Diverticulitis rarely causes bleeding

Diverticular bleeding:Management

 Most common cause of brisk

hematochezia (30-50% of cases)
 15% of patients with diverticulosis will
bleed
 75% of diverticular bleeding stops
without need for intervention
 Patients requiring less than 4 units of
PRBC/ day  99% will stop bleeding
 Risk of rebleeding  14-38%
Diverticular bleeding:
Management
 Resuscitation

 Localization

 Supportive care with blood products

Diverticular bleeding:
Localization
 Right colon is the source of diverticular
bleeding in 50-90% of patients

 Possible reasons
 Right colon diverticuli have wider necks
and domes exposing vasa recta over a
great length of injury
 Thinner wall of the right colon
Diverticular bleeding:Localization

Colonoscopy after rapid prepration

 Can localize site of bleeding

 Offers possible therapeutic

intervention (cautery, clip, etc)
Diverticular bleeding:
Management ( Cauterization )
 Diverticular bleeding:Management

 A site of active bleeding  Treated successfully with

was identified placement of two hemoclips
Diverticular bleeding: Surgery

 Surgery
 Segmental resection
 If
site can be localized
 Rebleeding rate of 0-14%

 Subtotal colectomy
 Rebleeding rate is 0%
 High morbidity (37%)

 High mortality (11-33%)

THANK- YOU