July 8, 2009 | In: ABDOMINAL SURGERY
48 DIVERTICULAR DISEASE OF THE COLON
Gregory P. Victorino M.D., Jyoti Arya M.D., Lawrence W. Norton M.D.
1. What is a colonic diverticulum?
Show answer
A protrusion of mucosa and submucosa through the muscular layers of the bowel wall. It has no muscular covering. Because diverticula do not involve all layers of the bowel wall, they are really “false” diverticula. Diverticulum formation may be related either to weakness of the bowel wall at the sites of vessel perforation or to increased intraluminal pressure caused by low dietary fiber and constipation.
2. What is the difference between diverticulosis and diverticulitis?
Show answer
Diverticulosis is colonic diverticula without associated inflammation. Diverticulitis is inflammation and infection. Only 15% of patients with diverticulosis develop diverticulitis.
3. How does a diverticulum cause pain?
Show answer
Pain apparently results from perforation of the diverticulum The resulting leakage may be scant and contained within pericolic fat or extensive, involving the mesentery, other organs, or the peritoneal cavity. Sigmoid diverticulitis typically causes pain in the left lower quadrant.
4. Where in the colon are diverticula usually located?
Show answer
In the United States, 95% of all diverticula occur in the left colon, primarily in the sigmoid colon. Diverticula, however, may occur anywhere in the colon. In Asia, right colonic diverticula are more common.
5. At what age is diverticulitis most common?
Show answer
The sixth or seventh decade of life. Patients younger than 50 with diverticulitis tend to have more complications. Younger patients are more likely than older patients to have right colonic diverticulitis.
6. What strategy may decrease diverticulitis in patients with diverticula?
Show answer
A diet high in fiber. Large bulk in the colon decreases segmentation and intraluminal pressure.
7. What is the best imaging test for diagnosing acute diverticulitis?
Show answer
Computed tomography (CT) scan, which can also diagnose local complications of diverticulitis.
8. What complications can result from perforation of a colonic diverticulum?
* Inflammatory phlegmon or abscess in the bowel mesentery
* Peritonitis
* Intra-abdominal abscess
* Internal fistula
* Bowel obstruction
9. Can diverticular disease cause bleeding?
Show answer
Yes. Diverticulosis (not-itis) is a common cause of lower gastrointestinal bleeding. Bleeding from diverticulitis is uncommon.
10. How can the site of diverticular bleeding be localized?
Show answer
It is localized with angiography performed via the inferior mesenteric artery and, if necessary, the superior mesenteric artery. Tagged red blood cell studies are less useful. Colonoscopy is rarely helpful.
KEY POINTS: LOCALIZATION OF LOWER GI BLEEDING
1. Common causes: diverticulosis, cancer, angiodysplasia.
2. Proctosigmoidoscopy without prep is helpful in ruling out rectal source of bleeding (more proximal bleeding lmiits the utility of endoscopy).
3. Tagged red blood cell nuclear scans are useful for slower GI bleeding (detects bleeding at 0.2-0.5 mL/min).
4. Arteriography is the preferred imaging modality because it can be therapeutic and detects bleeding at 0.5-2 mL/min.
5. Start arteriography with the IMA, then the SMA, then the celiac axis if necessary; administer vasopressin or embolize (85% success rate).
11. When should an operation be performed for a bleeding colonic diverticulum?
Show answer
Replacement of 5-6 units of blood (two thirds of a patient’s blood volume) within 24 hours and rebleeding during hospitalization are standard indications for resection of the segment of colon containing a bleeding diverticulum.
12. If bleeding is life threatening but cannot be localized within the colon, what treatment is required?
Show answer
Subtotal colectomy with ileostomy and closure of the distal sigmoid colon at the peritoneal reflection (Hartmann’s operation) or total abdominal colectomy with ileorectal anastomosis is required.
13. Which three procedures may be used when perforation of the diverticulum results in an abscess? Which has the lowest operative mortality rate?
Show answer
1. Diverting colostomy and abscess drainage (first of three stages)
2. Resection of involved colon with proximal colostomy and distal mucous fistula or closure by Hartmann’s operation (first of two stages)
3. Resection with primary anastomosis (one stage)
Operative mortality is lowest after resection and proximal colostomy for fecal diversion. Despite reports of success with the one-stage procedure, most surgeons favor a safer two-stage approach for perforated diverticulitis (this strategy requires a second operation after 3 months for colostomy takedown and colonic re-anastomosis).
14. What is the clinical evidence of a vesicocolic or ureterocolic fistula after diverticular perforation?
Show answer
Pneumaturia, fecaluria, and chronic urinary tract infections (polymicrobial).
15. What procedure is required to repair a vesicocolic fistula?
Show answer
A staged procedure was the standard until recently. Now most patients can be treated with a single procedure that includes sigmoid resection, colonic anastomosis, and primary repair of bladder defect with absorbable suture. A Foley catheter is usually left in place for 10 days after surgery. Some viable tissue should be placed between the colonic and bladder repairs to prevent a recurrent fistula.
References
WEB SITE
http://www.acssurgery.com/abstracts/acs/acs0327.htm
BIBLIOGRAPHY
1. Bouillot JL, Berthou JC, Champault G, et al: Elective laparoscopic colonic resection for diverticular disease: Results of a multicenter study in 179 patients. Surg Endosc 16:1320-1323, 2002. Full article
2. Eijbouts QA, de Haan J, Berends F, et al: Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques. Surg Endosc 14:726-730, 2000.
3. Faynsod M, Stamos MJ, Arnell T, et al: A case-control study of laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg 66:841-843, 2000. Medline Similar articles
4. Gooszen AW, Tollenaar RA, Geelkerken RH, et al: Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 88:693-697, 2001. Medline Similar articles Full article
5. Schwesinger WH, Page CP, Gaskill HV 3d, et al: Operative management of diverticular emergencies: Strategies and outcomes. Arch Surg 135:558-562, 2000. Full article
6. Simpson J, Scholefield JH, Spiller RC: Pathogenesis of colonic diverticula. Br J Surg 89:546-554, 2002.
7. Wolff BG, Devine RM: Surgical management of diverticulitis. Am Surg 66:153-156, 2000. Medline Similar articles Full article
8. Young-Fadok TM, Roberts PL, Spencer MP, et al: Colonic diverticular disease. Curr Probl Surg 37:457-514, 2000. Medline Similar articles
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February 7th, 2012 at 10:42 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
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February 7th, 2012 at 11:22 pm
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February 7th, 2012 at 11:28 pm
Websites we think you should visit…
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February 7th, 2012 at 11:49 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
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February 8th, 2012 at 3:09 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
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February 8th, 2012 at 8:03 am
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February 8th, 2012 at 8:33 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
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February 8th, 2012 at 8:47 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
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February 8th, 2012 at 8:53 am
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[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
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February 8th, 2012 at 9:31 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
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February 8th, 2012 at 2:24 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Scott Tucker Racing
February 8th, 2012 at 4:28 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Scott Tucker Racing
February 8th, 2012 at 4:31 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
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February 8th, 2012 at 4:39 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Scott Tucker Racing
February 8th, 2012 at 5:58 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……