diverticular disease [تم حفظه تلقائيا] 3.pptx

Diverticular disease

1. Diverticular Disease DR Muteb ALShammari GS Resident

2. Definition Diverticula :  blind pouches that protrude from the gastrointestinal wall and communicate with the lumen. True diverticulum : a type of diverticulum that affects all layers of the intestinal wall. Rare (except Meckel diverticulum) Typically congenital Occur less commonly in the colon Most commonly occur in the cecum False diverticulum or pseudodiverticulum: type of diverticulum that involves only the mucosa and submucosa and does not contain muscular layer or adventitia. Most common type of gastrointestinal diverticula Typically acquired Diverticulosis : the presence of multiple colonic diverticula without evidence of infection

3. Diverticulosis In the US, ∼ 50% of individuals > 60 years have diverticulosis  More common in high-income countries due to the higher prevalence of a high-fat, low-fiber diet Caused mainly by lifestyle and environmental factors: Diet (low-fiber, rich in fat and red meat) Obesity Low physical activity Increasing age Smoking Other causes: genetic factors: Connective tissue disorders (e.g., Marfan syndrome, Ehler-Danlos syndrome)  Autosomal dominant polycystic kidney disease

4. Pathophysiology The formation of diverticula is considered multifactorial. Increased intraluminal pressure, e.g., due to chronic constipation. Weakness of the intestinal wall Age-related loss of elasticity of the connective tissue Physiological gaps in the intestinal wall, which occur where blood vessels penetrate, predispose to protrusion and herniation of intestinal mucosa and submucosa. Localized particularly in the sigmoid colon Due to the narrow passage, intraluminal pressure is highest in the sigmoid colon, which promotes the formation of diverticula.

5. Clinical features Usually asymptomatic May manifest with abdominal discomfort or pain, especially if associated with chronic constipation  Diverticular bleeding Tenderness over the affected area. Mild abdominal cramps. Swelling or bloating

6. Diagnostics Asymptomatic diverticulosis: - Typically an incidental diagnosis  E.g., during a screening colonoscopy -No workup required Symptomatic diverticulosis: Colonoscopy: diagnostic modality of choice for suspected symptomatic diverticulosis   Indications : Lower GI bleed. Recurrent abdominal pain and/or diarrhea. Concern for underlying malignancy. Findings:  well-defined outpouching from the colonic wall Avoid if acute diverticulitis is suspected. Biopsy and histological analysis can be performed, if necessary

7. Imaging Double-contrast barium enema : highly sensitive test to detect diverticulosis but not commonly performed    Consider in the workup of the following:  Recurrent LLQ pain without signs of acute inflammation . Altered bowel habits . Lower GI bleed in a hemodynamically stable patient if colonoscopy cannot be performed. Contraindications : suspected diverticulitis or perforated diverticulum  Findings : outpouching of the colonic wall of variable size

8. Imaging Abdominal ultrasound Indications : may be performed as part of the workup for nonspecific LLQ pain Findings : outpouching from the colonic wall Colonoscopy: is the diagnostic modality of choice for symptomatic diverticulosis

9. Treatment Asymptomatic diverticulosis: No treatment can reverse the growth of existing diverticula. The goal is the prevention of progression Symptomatic uncomplicated  diverticular disease : Proposed therapies include  antibiotics  and probiotics, however, supportive evidence is lacking. It is possible that symptoms attributed to  diverticular disease  may be caused by  irritable bowel syndrome .

10. Complications Diverticular bleeding Diverticulosis is the most common cause of lower GI bleeding in adults . Occurs in ∼ 5% of individuals with diverticulosis Etiology : erosions around the edge of diverticula Clinical findings: Painless hematochezia Signs of anemia may be present if recurrent Severe or ongoing bleeding : significant drop in hemoglobin → hemodynamic instability (hypotension, tachycardia, dizziness, reduced level of consciousness) In 70–80% of cases, bleeding ceases spontaneously Differential diagnosis : other causes of lower gastrointestinal bleeding (e.g. hemorrhoidal bleeding)

11. Treatment: I nitial management of overt GI bleeding : Ensure patient is NPO. Insert two large-bore peripheral IVs (for possible fluid resuscitation and blood transfusion) and obtain blood samples for laboratory studies (e.g., CBC, type and screen). Conduct a focused history and examination (including DRE) Risk stratify to guide further management. Prior to hemostatic procedures: Administer pretreatment (e.g., IV PPI) as needed. IV  PPIs  can reduce the risk of  mortality  and rebleeding, however, their administration should not delay definitive hemostatic interventions or be prioritized over resuscitation measures for unstable patients. Administer anticoagulant reversal if INR > 2.5. Consider withholding antithrombotic agents.

12. Stable patients: Restrictive transfusion strategy (transfuse pRBCs if Hb ≤ 7–8 g/dL). Refer for endoscopy (e.g., EGD or colonoscopy) according to risk stratification and source of bleeding Unstable patients: Follow an ABCDE approach. Consider intubation to protect the airway (e.g., in patients with altered mental state and/or severe ongoing hematemesis). Urgent volume resuscitation for hemodynamic instability IV fluid resuscitation Liberal transfusion strategy: for hemorrhagic shock or massive bleeding Target normal vital signs prior to diagnostic testing if possible.

13. After stabilizations Endoscopic hemostasis during colonoscopy (e.g., epinephrine injection, thermal coagulation, ligation) Angiography with vessel embolization Performed if bleeding cannot be localized or treated during endoscopy

14. Diverticulitis Occurs in ∼ 4–20% of individuals with  diverticulosis most commonly in the  sigmoid colon Inflammation : Most commonly :  chronic inflammation  and increased intraluminal pressure → erosion of diverticula wall →  inflammation  and bacterial translocation Rarely : stool becomes lodged in diverticula → obstruction of intestinal lumen →  inflammation

15. Clinical features Sigmoid colon most commonly affected → left lower quadrant pain Possibly tender, palpable mass (pericolonic inflammation) Fever Change in bowel habits (constipation in ∼ 50% of cases and diarrhea in 25–35% of cases) Acute abdomen : indicates possible perforation and peritonitis ↑ Urinary urgency and frequency (in ∼ 15% of cases) Rarely : hematochezia

16. Diagnostics Suspect acute diverticulitis in adult patients presenting with  LLQ   pain ,  fever , and  leukocytosis Laboratory studies CBC: leukocytosis, possible anemia BMP: electrolyte abnormalities, ↑ BUN, ↑ creatinine CRP: ↑ CRP FOBT: positive in patients with diverticular bleeding Diverticulitis is highly likely in patients with  LLQ   pain  and tenderness, no vomiting, and  CRP  > 50 mg/L.

17. Imaging CT abdomen and pelvis with IV contrast Indications Preferred initial imaging modality for suspected diverticulitis   Diagnostic confirmation in patients with no prior imaging studies  Staging the severity of diverticulitis Supportive findings Colonic outpouching Signs of inflammation  Bowel wall thickening > 3 mm Peridiverticular mesenteric fat stranding Complications may also be identified Peridiverticular abscess:  hypodense  collections with peripheral contrast enhancement Diverticular perforation:  pneumoperitoneum Intestinal obstruction: dilated intestinal loops with multiple air-fluid levels

18. Imaging MRI  abdomen and  pelvis  (without and with IV contrast) Indications : suspected diverticulitis in patients with contraindications to CT Ultrasound  abdomen Indications Formal ultrasound is typically considered as an alternative to  MRI  in patients with contraindications to CT  Point-of-care ultrasound  may be considered as an initial imaging modality and can show findings of  complicated diverticulitis  (e.g.,  pneumoperitoneum , free fluid,  abscess  formation).  Supportive findings: diverticula with surrounding  inflammation ,  abscess  formation (detectable fluid), bowel wall thickening 

19. Imaging Abdominal x-ray   Not useful in diagnosing  uncomplicated diverticulitis Indications Suspected perforation or  bowel obstruction May be performed as part of the routine workup for  acute abdominal pain Findings that may be seen in  complicated diverticulitis  include Bowel perforation :  pneumoperitoneum Bowel obstruction : dilated bowel loops and multiple air-fluid levels Screening colonoscopy   Recommended 6–8 weeks after the resolution of the acute episode to assess the extent of diverticulitis and rule out  malignancy    Colonoscopy is contraindicated during an acute episode because of the increased risk of perforation.  Not required if a recent evaluation of the  colon  has been performed Avoid colonoscopy during the acute phase of diverticulitis because of the risk of perforation!

20. CLASSIFICATIONS

21. Differential diagnoses Crohn’s disease, ulcerative colitis Colorectal cancer Intestinal ischemia (ischemic colitis) Acute appendicitis Ileus , colonic obstruction Ectopic pregnancy Ovarian torsion Ovarian cancer Inguinal hernia Renal colic Urinary tract infection

22. Treatment Uncomplicated diverticulitis Conservative management   Consider broad-spectrum oral  antibiotics   Complicated diverticulitis   Antibiotic therapy :  broad-spectrum IV  antibiotics  are routinely recommended Management of complications abscess: Size < 4 cm: trial of conservative management with IV  antibiotics Size ≥ 4 cm Ultrasound - or CT-guided percutaneous drainage Consider laparoscopic or open surgical drainage if percutaneous drainage is not feasible. Continue IV  antibiotic therapy . Send aspirate or  pus  for cultures and tailor  antibiotic  treatment accordingly.

23. Treatment Perforation with generalized peritonitis:  emergency surgery  Hemodynamically stable patients: laparoscopic or open colectomy and  primary anastomosis  with/without a temporary diverting  stoma   Critically ill patients :  Hartmann procedure

24. Complications Perforation   Locally-contained perforation: can lead to the formation of an  abscess  or phlegmon   Intraperitoneal perforation Caused by: Rupture of an inflamed diverticulum → free communication with the  peritoneum  → generalized fecal peritonitis Rupture of a diverticular  abscess  → generalized  purulent  peritonitis Can present with symptoms of  acute abdomen  and widespread intraperitoneal free air on imaging Abscess   Peridiverticular localization Causes symptoms similar to those of acute diverticulitis Suspect an  abscess  in patients with persistent  fever  and abdominal  pain  despite  antibiotic  treatment. Intestinal obstruction  (rare)  Etiology Narrowing due to inflammatory swelling Compression through  abscesses Ileus  caused by localized irritation

25. Complications Clinical findings Abdominal pain and distention Constipation Nausea, vomiting Acute abdomen Fistulas    Epidemiology Most commonly colovesical Other forms: colovaginal, coloenteric, colocutaneous Clinical findings Pneumaturia  and  fecaluria May cause recurring  urinary tract infections , including urosepsis Diagnosis: CT with oral contrast Localized thickening of the  colon  and  bladder Air or contrast material in the  bladder Treatment Resection and  primary anastomosis Antibiotics  if surgery is not possible

26. Complications Recurrent diverticulitis   13–23% of patients with  uncomplicated diverticulitis    Up to 40% of patients with  complicated diverticuliti s