Diverticular Disease Of The Colon
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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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Pneumaturia, fecaluria, and chronic urinary tract infections (polymicrobial).
15. What procedure is required to repair a vesicocolic fistula?
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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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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
