Diverticular Disease Christopher Gross Gillian Lieberman, MD - - PowerPoint PPT Presentation

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 40yo 30% at 60yo 65% at 80yo 20% of those present with sxs

Risk factors:

“disease of Western Civilization”

low fiber constipation

• besity, 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

• f 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 exaggerated 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

• n 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%)

• Intramural sinus tract (with air or contrast) with

thickened wall

Fistulas Perforation Obstruction

Fat stranding Wall thickening

http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow228arr.jp

Companion Pt 3 + 4: Percutaneous Drainage of Diverticular Abscess

• Percutaneous

Drainage: Seldenger Technique with 12 French gauge locking pigtail catheter

5cm abscess, Stage 2

Pigtail catheter

Halligan, et al. “Imaging Diverticular Disease” http://www.emedicine.com/radio/images/336139‐367320‐6366.jpg

Thickened walls, sigmoid abscess

What does our patient’s CT show?

Our Pt KB: Pelvic Fistula on Pelvic CT

small sinus tract in pelvis communicating w/ rectosigmoid colon, dilated sigmoid Small sinus tract Enteroenteric fistula Colocolonic fistula

PACS

6cm

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://myweb.lsbu.ac.uk/dirt/museum/margaret/838-2454a-1480410.jpg http://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html

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

Elective Surgery: 6-8wks later One episode of complicated 2 confirmed episodes that require hospitalization Immunocompromised

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)

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):649-
• 662. Review
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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
• perate? “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: 631-

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