GASTROINTESTINAL SYSTEM BLOCK

CASE 5A

Ronald Chrisbianto Gani 405090223 Faculty of Medicine 2009 Tarumanagara University

DIVERTICULAR DISEASE

DIVERTICULAR DISEASE
Higher incidence in age >60 years Only 20% develops symptomatic disease Male tends to present in younger age Two types of diverticula
True diverticula
saclike herniation of entire bowel wall

Pseudodiverticula (most common)

A protrusion of the mucosa through muscularis propria

Mostly affect the sigmoid colon, associated with high pressure zone and stool retention Diverticulitis : inflammation of diverticula, associated with fecalith, may lead to perforation or bleeding
Harrisons Principle of Medicine 17th ed Vol I

DIVERTICULAR DISEASE

CLINICAL PRESENTATION
BLEEDING
Only 20% pts of diverticulitis has GI bleeding Self-limited and stops with bowel rest Lifetime risk of rebleeding is 25% Diagnosed and managed by colonoscopy and angiography Mesenteric angiography con localize and occlude 80% cases Segmental resection may eliminate the risk of further bleeding advantageous in patient with chronic blood thinner Harrisons Principle of Medicine
17th ed Vol I

CLINICAL PRESENTATION
DIVERTICULITIS
Best diagnosed by CT : sigmoid diverticula, thickened colon wall >4mm, inflammation Must be distinguished from : IBS, Ovarian Cyst, Endometriosis, Acute Aooendicitis, Pelvic Inflammatory disease, Sigmoid malignancy Barium enema should not be performed in acute setting
Harrisons Principle of Medicine 17th ed Vol I

HINCHEY CLASSIFICATION

Harrisons Principle of Medicine 17th ed Vol I

MANAGEMENT
MEDICAL MANAGEMENT
Asymptomatic : diet alteration to eat fiberenriched diet, supplementary fiber, avoid nuts and popcorn Simptomatic
Antibiotic : Trimethoprim/Sulfamethoxazole or Ciprofloxacin and Metronidazole. +Ampicillin for non responder. 3rd gen penicillin may be effective. All antibiotics are given for 7-10 days Bowel rest and diet limitation
Harrisons Principle of Medicine 17th ed Vol I

MANAGEMENT
SURGICAL MANAGEMENT
Removal of diseased sigmoid rectosigmoid juntion Mostly done by Hartmaan method Can be open sigmoid resection or laparoscopic sigmoid resection Preoperative risk factors influencing post-operative mortality rates Surgical therapy offered to pts with 2 documented attacks of diverticulitis requiring hospitalization Younger pts should not wait for 2 attacks Goal : controlling sepsis, eliminating complication, restoring intestinal continuity, minimizing morbidity, length of hospitalization Harrisons Principle of Medicine
17th ed Vol I

MANAGEMENT

Harrisons Principle of Medicine 17th ed Vol I

MANAGEMENT

Harrisons Principle of Medicine 17th ed Vol I

PROGNOSIS
Reccurence in 10% patient post-operative
Inadequate surgical resection retained diseased segmental IBS initial symptoms

Harrisons Principle of Medicine 17th ed Vol I