Acute Diverticulitis.pptx

Dr. Kou Pou Kuan

1. Acute Diverticulitis 2022/10/28 Presented by: Dra Kou Pou Kuan ( IC of Emergency Medicine ) Supervisor: Dra Ng Wai Lon

2. Content Case What is it? How to diagnosis? How to assessment? What is the plan?

3. Case 60y/F, Hx of Pulmonary tuberculosis sequelae Denied smoking and drinking alcohol. Mother had cholangiocarcinoma Complain Fever and lower abdominal pain for 1 week Pain: persistent, dullness, no radiating pain Frequency with urgency of urination No vomiting or nausea , no tenesmus , no hematochezia Bowel habit was normal Present illness : 21/02/2022

4. 1 Physical examination(ER): T: 38.2, Bp: 108/74mmHg, P 107bpm, SpO2 98%(RA ) APC: No ralse , HR regular ABD: One surgical scar is visible in the middle of the abdomen. Soft, flat, tenderness on lower middle abdomen, no rebound tenderness , McBurney point (-), bowel sound normal active, bilateral costal spine angle percussion was negative Digital rectal exam: Yellowish stool, no mass

5. 1 Comp . Exam (21/02/2022) Na 134, K 3.6, Cl 103 AST/ALT: 20/14 Hb 14.5g, WBC 23 x10^9/L( Neu 88.2%), Platelet 384 CRP: 9.19, PCT 0.14 Urine II: Normal Blood and urine culture: Negative CT of the Abdomen and Pelvis with Contrast Diverticulitis of sigmoid colon with peri-diverticular abscess( 5.2x6.1x5.7cm , air locules ), inflammatory process involving the bladder and the adjacent ileum

6. 1 Impression : Acute sigmoid diverticulitis with peri-diverticular abscess Flagyl 500 mg q8h + Rocephine 1g q12h Treatment :

7. Diverticulum “Bulges” in large intestine due to weakened bowel walls True: All 3 layers (Mucosa, submucosa, muscular layer) (eg, Meckel diverticulum) Pseudo: Mucosa, submucosa (Zenker diverticulum) Diverticulitis Gastrointestinal disorder involving inflammation of diverticula (Fecolith across divericular)

8. Epidemiology Mortality and Morbidity - 15- 25% require surgical therapy - 7.7%( If peritonitis is present) Age( increases with age) Race - Asians : Right sided diverticulitis - Western: Left sided diverticulitis Common: Sigmoid colon Western Countries Location Left colon involvement 95% Left plus right colon 5% Right colon only: Rare Type Pseudo - diverticula Prevalence Increases with age Number of diverticula increases with age Main complication Diverticulitis Asian Countries Location Right colon involvement 90% Left plus right colon 10% Left colon only: Rare Type True diverticula Prevalence Stable with age Number of diverticula stable with age Main complication Bleeding Diverticular disease: Epidemiology and management . Adam V Weizman, MD, FRCPC1 and Geoffrey C Nguyen, MD PhD FRCPC . Can J Gastroenterol. 2011 Jul; 25(7): 385–389.

9. Pathophysiology Increased intraluminal pressure -Associated with lack of dietary fibre Degenerative changes in colonic wall -Usually at point of entry of terminal arterial branches (Branch of inferior mesenteric artery) where serosa is weakest -Associated with weakening of collagen structure with age Diverticular Disease: An Update on Pathogenesis and Management . Mona Rezapour, Saima Ali, and Neil Stollman . Gut Liver. 2018 Mar; 12(2): 125–132. 2017 May 12. doi: 10.5009/gnl16552

10. Risk factor Increasing Age Diet- L ow in dietary fiber and high in refined carbohydrates Lack of vigorous physical activity Smoking Hight BMI NSAID use

11. Clinical Manifestations Pain - Typically located in left lower quadrant - Constant pain, may be diffuse - Right sided (Congenital?) Fever - Almost invariably present - High grade fever and sepsis Bowel Habit change, rectal bleeding Nausea & Vomiting Urinary urgency, Frequency, Dysuria

12. Complicated diverticulitis Localized sigmoid thickening (>5 mm) Inflammation of pericolic fat Abscess (phlegmon) Frank(Free) perforation Obstruction Fistulization Large phlegmon Peritonitis Severe Diverticulitis Mild Diverticulitis Classification---CT scan Uncomplicated diverticulitis

13. Hinchey classification

14. Evaluation CRP> 50 mg/l

15. Inpatient Vs Outpatient Acute Complicated diverticulitis Acute uncomplicated diverticulitis PLUS 1) Sepsis, 2) Microperforation or phlegmon, 3) Immunosuppressed patient or Significant comorbidities, 4) Fever > 39C, 5) Signifiant leukocytosis, 6) Age >70 years, 7) Intolerance of oral intake, 8) Severe abdominal pain/ peritonitis, 9) Failed outpatient treatment Uncomplicated Diverticulitis without other associated issues = outpatient treatment

16. Oral antibiotic(7-10 days) Ciprofloxacin (500 mg q 12h) + M etronidazole (500 mg q 8h) Levofloxacin (750 mg daily) + Metronidazole (500 mg q8h) Trimethoprim-sulfamethoxazole (160mg/800 mg q12h) plus metronidazole (500 mg q8h) Amoxicillin-clavulanate (875 mg/125 mg) q8h or Augmentin XR q12h Moxifloxacin (400 mg daily; use in patients intolerant of both metronidazole and beta-lactam agents)

17. Low-risk community-acquired intra-abdominal infections

18. High-risk community-acquired intra-abdominal infections

19. Emergency surgery for acute diverticulitis Frank perforation(Hinchey III and IV) (1C) Microperforation with peritonitis (1C) Develop ileus or bowel obstruction (1C) Nonoperative management of acute diverticulitis fails (1C)

20. Perforation

21. Unstable D amage control surgery : “I ethal triad ”--- metabolic acidosis, hypothermia, and increased coagulopathy

22. Stable

23. Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis.

24. Technical considerations The extent of elective resection should include the entire sigmoid colon with margins of healthy colon and rectum. Non inflammed tissue should be used for anastomosis Not necessary to remove all diverticula A leak test of the colorectal anastomosis should be performed

25. Long term management C olonoscopy (6-8 weeks ) - Complicated diverticulitis with imaging abnormalities or atypical courses Abdominopelvic computed tomography imaging may be repeated to rule out a new complication Cancer, Chronic smoldering diverticulitis

26. After a first occurrence of acute diverticulitis, the 5-year recurrence rate is 20%. The risk of further complications and need for emergency surgery < 5 % 30% remain asymptomatic 20% with chronic abdominal pain

27. Antibiotic 1 week CT of the Abdomen and Pelvis with Contrast The abscess in the pelvic is diminished in size( 5.2x6.1x5.7 -> 3 x 3.8 cm) Soft diet 28/02 Antibiotic 2 weeks Fever Tmax 38C, PE: normal WBC 8.6x 10^9/L, CRP 0.38 Colonscopy: Multiple tiny diverticular at Sigmoid 07/03 Back to Case 24/02 Admitted Flagyl 500 mg q8h + Rocephine 1g q12h Liquid diet IR doctor refuse drainage 25/02 08/03 Diagnostic laparoscopy

28. 29/03 CT of the Abdomen and Pelvis with Contrast: Normal WBC 10 x 10^9/L(Neutro 83%), CRP 1 mg/dL General diet, Change Flagyl + Fortum Discharge Remove drainage 15/03 Fever, wound infection, Drainage: 168ml, clear. WBC 19.3 x 10^9/L(Neutro 83%), CRP 3.58 mg/dL CT of the Abdomen and Pelvis with Contrast No focal fluid collection throughout the abdomen and pelvis. Wound culture Escherichia coli Fasting with TPN, Change Meropenem 1g q8h 29/03 4/4 22/03 Drainage: 10 ml-> Liquid diet Case

29. Take home messages Hinchey classification guide the treatment Antibiotic consider withholding in mild cases Surgery is individualized Unstable: Hartmann's procedure Follow up colonoscopy

30. Reference Crowe FL, Balkwill A, Cairns BJ, et al; Million Women Study Collaborators; Million Women Study Collaborators. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut. 2014;63:1450–1456. A une D, Sen A, Leitzmann MF, Tonstad S, Norat T, Vatten LJ. Tobacco smoking and the risk of diverticular disease - a system_x0002_atic review and meta-analysis of prospective studies. Colorectal Dis. 2017;19:621–633. Suhardja TS, Norhadi S, Seah EZ, Rodgers-Wilson S. Is early co_x0002_lonoscopy after CT-diagnosed diverticulitis still necessary? Int J Colorectal Dis. 2017;32:485–489. Bolkenstein HE, van de Wall BJ, Consten EC, van der Palen J, Broeders IA, Draaisma WA. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol. 2018;53:1291–1297.25. Stollman N, Smalley W, Hirano I; AGA Institute Clinical Guide_x0002_lines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015;149:1944–1949. Mege D, Yeo H. Meta-analyses of current strategies to treat uncomplicated diverticulitis. Dis Colon Rectum. 2019;62:371–378. Emile SH, Elfeki H, Sakr A, Shalaby M. Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis, and meta-regression of predictors of treatment failure. Tech Coloproctol. 2018;22:499–509. Lambrichts DPV, Bolkenstein HE, van der Does DCHE, et al. Multicentre study of non-surgical management of diverticulitis with abscess formation. Br J Surg. 2019;106:458–466.