Diverticular Disease

1. Diverticular Disease Ateet H. Shah, M.D. Colon and Rectal Care September 8, 2009

5. Do I have to tell my friends that Daddy is a colorectal surgeon?

6. Diverticular Disease Ateet H. Shah, M.D. Colon and Rectal Care September 8, 2009

7. Introduction • Continuum of anatomic and physiologic change due to diverticula • Diverticula • Sac-like protrusion of the colonic wall • Most often in sigmoid colon • Diverticular disease • Asymptomatic disease (diverticulosis) • Symptomatic disease: hemorrhage, simple diverticulitis, complex diverticulitis (abscess, fistula, obstruction, free perforation)

8. Introduction • Epidemiology • Pathophysiology • Clinical presentation • Diagnosis • Treatment • Controversy • Alternate theories of pathophysiology • Medical management • Indications for surgery

9. Epidemiology • First described in mid-19th century • First resection in 1907 at Mayo Clinic • Increasing prevalence since early 20th century in industrialized countries • Increased incidence with age and low fiber diet • Obesity and lack of physical activity may also play a role

10. Epidemiology • Disease of Westernized countries • Prevalence of 5-45% vs Asia/Africa with prevalence of <0.2% • Left-sided disease more common in West • Significant impact on U.S. healthcare costs • 2 million office visits • 450,000 hospital visits • 3000 fatalities • $2.4 billion

11. Epidemiology • Risk of diverticulosis in U.S • 5% at age 40 • 30% at age 60 • Up to 80% at age 80 • 15-25% develop diverticulitis • 10-20% require hospitalizaation • Of hospitalized patients, 20-50% require operative intervention • Overall, only 1% of patients require surgery

12. Pathophysiology of Diverticulosis • Develop where vasa recta penetrate bowel wall • Increased luminal pressure herniates bowel wall • 95% occur in sigmoid colon (highest pressure) • Dietary fiber lowers colonic pressure

13. Pathophysiology of Diverticulosis • Pathologic changes associated with diverticular disease • Contracted, thickened appearance (mychosis) • Muscle hypertrophy, increased elastin deposition • Connective tissue changes • Patients Marfan and Ehlers-Danlos syndromes develop diverticula at a young age

14. Pathophysiology of Diverticulitis • Inflammation of diverticulum • Microscopic or macroscopic perforation of diverticulum • Exact mechanism not completely understood • Obstruction of diverticulum by fecalithrare

15. Pathophysiology of Diverticulitis • Erosion of diverticular wall by increased intraluminal pressureinflammation and focal necrosis • Frequently mild • Uncomplicated attack • Localized abscess • Involving adjacent organsfistula or bowel obstruction • Poor containmentfree perforation and peritonitis

16. Pathophysiology of Diverticulitis:Alternate Theories • Altered peridiverticular colonic flora and low grade chronic inflammation • Leads to intermittent periods of active disease similar to inflammatory bowel disease • May explain chronic diverticular disease, including segmental colitis associated with diverticula (SCAD) • Utility of medical therapy (rifaximin, 5-ASA, probiotics) for treatment

17. Pathophysiology of Bleeding • Vasa recta draped over dome—chronic injury • Occurs in absence of diverticulitis • Right-sided diverticula with wider necks and domesgreater risk of bleeding

18. Clinical Patterns • Asymptomatic disease (70%) • Acute diverticulitis (15-25%) • Chronic diverticular disease (<5%) • Diverticular bleeding (5-15%)

19. Clinical Patterns • Asymptomatic disease (70%) • Acute diverticulitis (15-25%) • Chronic diverticular disease (<5%) • Diverticular bleeding (5-15%)

20. Clinical Patterns • Asymptomatic disease (70%) • Acute diverticulitis (15-25%) • Chronic diverticular disease (<5%) • Diverticular bleeding (5-15%)

21. Acute Diverticulitis • Presentation depends upon severity of underlying inflammatory process • Uncomplicated diverticulitis (75%): pericolonic inflammation • Complicated diverticulitis (25%): abscess, fistula, obstruction, perforation Surgery recommended for complicated diverticulitis

22. Acute Diverticulitis: Symptoms • LLQ abdominal pain • Redundant sigmoidRLQ pain • Radiates to back, flank, groin, leg • Fever • Generally no nausea, vomiting • Bleeding atypicalconsider ischemic colitis, cancer • Dysuria, urgencybladder involvement • Pneumaturia, fecaluriacolovesical fistula • Passage of gas, stool from vaginacolovaginal fistula

23. Acute Diverticulitis: Exam • Fever • LLQ tenderness • RLQ tenderness (redundant sigmoid) • Diffuse peritonitisperforated disease • Elevated WBC

24. Acute Diverticulitis: Differential Diagnosis • IBS • Gastroenteritis • Bowel obstruction • Inflammatory bowel disease • Appendicitis • Ischemic colitis • Colorectal cancer • UTI • Kidney stone • Gynecologic disoders

25. Acute Diverticulitis: Diagnostic Testing • CXR, AXR • More useful in ruling out other causes (pSBO, kidney stone) • Free airperforation Free air

26. Acute Diverticulitis: CT scan • CT scan is diagnostic test of choice • Diagnosis • Assessment of severity • Therapeutic intervention • Quantification of resolution Mild diverticulitis Diverticular abscess

27. Acute Diverticulitis: CT scan • Pericolic fat stranding • Colonic diverticula • Bowel wall thickening • Soft tisssue mass representing phelgmon • Pericolic abscess Mild diverticulitis Diverticular abscess

28. Acute Diverticulitis: CT scan • Identifies complications • Peritonitis • Fistula formation • Obstruction • CT stages disease • Predicts risk of recurrent attacks • Predicts failure of medical treatment • Therapeutic modality Bladder air = Colovesical Fistula

29. Acute Diverticulitis: Contrast Enema • CT unavailable • Evaluate colonic strictures • Demonstrate abscesses or fistulas • Bowel obstruction • Operative planning Colovesical Fistula

30. Acute Diverticulitis: Colonoscopy • Not used in acute setting • 6-8 weeks later • mandatory to rule out cancer • 20% of complicated diverticulitis caused by cancer

31. Acute Diverticulitis: Treatment • Uncomplicated diverticulitis (75%) • Majority respond to medical therapy • 30% may require surgery • Complicated diverticulitis (25%) • Nearly all require surgery

32. Acute Diverticulitis: Treatment • Uncomplicated diverticulitis (75%) • Majority respond to medical therapy • 30% may require surgery • Complicated diverticulitis (25%) • Nearly all require surgery

33. Uncomplicated Diverticulitis • Bowel rest and antibiotics • Successful 70-100%

34. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

35. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

36. Outpatient Treatment? • Severity of presentation, ability to tolerate oral intake, presence of comorbid conditions, and available support • Outpatient treatment • Reliable • Increased pain, inability to tolerate POcome back • Hospitalize • Elderly, immunosuppressed, significant comorbidities, high fever and WBC

37. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • GNR and anaerobes (E. coli and B. fragilis) • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

38. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

39. Dietary Recommendations • High fiber diet • ? Popcorn, seeds, nutshistorically discouraged • Biologic mechanisms of diverticulitis incompletely understood • No evidence to support this recommendation

40. Dietary Recommendations • Strate et al. JAMA 2008; 300:907 • 47,228 men followed for 18 years • No increase in risk of diverticular complications with consumption of nut, corn, popcorn • 50% of colorectal surgeons believe avoidance is important

41. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

42. Medical Treatment • Recurrent disease • Patients unfit for surgery • Standard approach is debated • Most literature is European

43. Medical Treatment: Rifaximin • Non-absorbable antibiotic • Unknown mechanism of action • Decreased bacterial overgrowthdecreases mucosal inflammation • Decreased metabolic activity of gut floradecreased breakdown of dietary fiber and production of intestinal gas • Literature • Rifaximin + fiber improves symptoms from diverticular disease and decreases recurrent episodes of acute diverticulitis

44. Medical Treatment: Mesalamine • 5-ASA compound used in inflammatory bowel disease • ? Low-level chronic inflammation as the etiology of diverticulitis • Three uncontrolled Italian studies of mesalamine +/- rifaximin • Addition of mesalamine improves symptoms of chronic diverticular disease • Decreases recurrent episodes of diverticulitis

45. Medical Treatment: Probiotics • Altered peridiverticular microflora and chronic mucosal inflammation as a contributing factor to diverticulitis • Very little literature other than two small studies • Needs additional study

46. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Colonoscopy 6-8 weeks • Recommendation for surgery

47. Uncomplicated Diverticulitis • Can treatment be given outpatient? • Selection of antibiotics • Dietary recommendations • Medical treatment • Follow-up investigation • Recommendation for surgery

48. Prognosis • 30-40% of patients remain asymptomatic • 30-40% have episodic abdominal cramps without frank diverticulitis • 30-40% have second attack of diverticulitis

49. Indications for Resection • Current recommendation by American College of Gastroenterology (ACG), European Association for Endoscopic Surgery (EAES)resection after 2nd attack • American Society of Colorectal Surgery (ASCRS)recently amended its recommendations Indications for surgical resection for recurrent, uncomplicated disease still controversial

50. Elective Resection • Sigmoid resection • Rationale • Recurrent diverticulitis gives rise to more serious complications • Response of conservation treatment decreases with each episode of diverticulitis • Elective surgery is safer than emergency surgery