Diverticulitis

Nomenclature
Diverticulum = sac-like protrusion of the colonic wall

Diverticulosis = describes the presence of diverticuli

Diverticulitis = inflammation of diverticuli

 Diverticulitis
 Definition
• Inflammation of a diverticulum, is related to the
retention of particulate material within the
diverticular sac and the formation of a fecalith
• Actually an extraluminal pericolic infection caused
by the extravasation of feces through the
perforated diverticulum
 Presentation
• LLQ pain : may radiate to the suprapubic, groin,
back
• Bowel habit change, Anorexia, Fever, Chill,
Urinary urgency
Associated symptoms
Nausea/vomiting 20-62%
Constipation 50%
Diarrhea 25-35%
Urinary symptoms (dysuria, urgency, frequency)
10-15%
 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
 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
 Diverticulitis
 Physical Findings
• Dependent on the site of perforation, the amount
of contamination, and the presence or absence
of secondary infection of adjacent organs
• Tenderness, Muscle guarding
• Tender mass : phlegmon or abscess
• Abdominal distension : ileus or obstruction
• Tender fluctuant pelvic mass on rectal or vaginal
exam
 Diverticulitis
 Diagnostic Tests
• 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
• MRI, US
• 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
 Disease not associated with free intraperitoneal
perforation, fistula formation, or obstruction
 Nonoperative treatment
• Bowel rest + Antibiotics ; 75% response
• Trimethoprim/sulfamethoxazole or ciprofloxacin
and metronidazole ; aerobic gram-negative rods
and anaerobic bacteria
• The addition of ampicillin to this regimen for
nonresponders ; enterococci
• Single-agent therapy ; a third-generation penicillin such
as piperacillin
• The usual course of antibiotics is 7 to 10 days
 Uncomplicated Diverticulitis
 Investigative studies
• After the symptoms have subsided for at least 3 weeks
• To establish the presence of diverticula and to exclude
cancer, which can mimic diverticulitis
• Colonoscopy > Barium enema
 Recurrent disease
• Second attack (<25%) -> Third attack (>50%)
• Elective resection
 After infection control ; usually 4 to 6 weeks after the episode
 Laparoscopic resection ; growing trend
 Immunocompromised patient : after single attack
 Complicated Diverticulitis
 Hinchey classification
• Stage I: Pericolic or
mesenteric
abscess

• Stage II: Walled-off

pelvic abscess

• Stage III: Generalized

purulent peritonitis

• Stage IV: Generalized

fecal peritonitis
 Complicated Diverticulitis
Abscess
 Usually confined to the
pelvis
 Significant pain, fever, and
leukocytosis
 More than 2cm ; should be
drained
• Percutaneous or transanal >
laparotomy
 Elective surgery ; after
6weeks following drainage
• Complete removal of the entire
abnormally thickened bowel
 Complicated Diverticulitis
Fistula
 Skin, bladder, vagina, or small bowel
 Sigmoid-vesical fistula
• Pneumaturia, fecaluria,
and recurrent UTI (Urosepsis)
• CT ; may demonstrate
air in the bladder
• Barium enema, IVP,
Cystoscopy
 Treatment
• Initial treatment ; infection control and reduce the
associated inflammation
• Rarely a cause for emergency surgery
• Diagnostic steps such as coloscopy should be taken to
confirm the cause of the fistula before a definitive
operation is undertaken.
 Generalized Peritonitis
 Mechanism
• Perforation without sealing by the body’s normal
defenses -> contaminated with feces
• Abscess burst into the unprotected peritoneal
cavity
-> contaminated with enteric bacteria
 Immediate operative intervention
• Excise the segment of colon containing perforation and
construct a colostomy using noninflammed colon
• Peritoneal cavity irrigation, iv antibiotics
 Colostomy repair
• Usually after a period of at least 10 weeks
 References
 Sabiston Textbook of Surgery 17ed
 Harrison’s Principles of Internal Medicine 16th
 Whetsone D, Hazey J, Pofahl WE 2nd, Roth JS. Current
management of diverticulitis. . 2004 Jul-
Aug;61(4):361-5
 Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of
elective colectomy in diverticulitis: a decision analysis.
. 2004 Dec;199(6):904-12.
 Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid
colectomy after acute diverticulitis: when to operate?
. 2004 Oct;136(4):725-30.
 Park JK et al. Clinical analysis of right colon diverticulitis.
2003 Jan;64:44-48
 Chang JH et al. Surgical treatment of the colonic
diverticulosis. 2002 May;62:415-
420
Thank you