Diverticular Diseases

What to know ?• Diverticulosis is a condition that develops

when pouches form in the wall of the colon.• False and true • The most known true is Meckel's 

Meckel's diverticulum: The rule of 2's• 2% of the population.• 2 feet of the ileocecal valve.• 2 inches in length.• presentation before the age of two.

• Wall layers of the intestine• Natural opening of the vasa recta • Mucosa and submucosa • Anywhere but sigmoid most common• Sigmoid “left” → pressure • Right colon is common in Asian usually true and in general is rare• The etiology of diverticulosis is inconclusive • Diverticulitis Etiology is not clear • Inflammation >>> bacterial growth >> distention >>>

compromised blood supply >> perforation (macro OR micro) >>> peritonitis and other complications

• Fistula formation (colovesical is common in males and colouterus in females )

• Uncommonly (in females) colocutaneous and colovaginal

Pathophysiology

• Less than 5% before the age of 40• Increased incidence with the number of diverticulosis (15-20%)• Only 20% younger than 50 years• Industrial countries >>> lifestyle• Asian countries adopted this lifestyle

Epidemiology

Prognosis• Coexisting conditions• Younger patients• Immunosuppressed• Complication• Abscess • Fistula • Intestinal rupture • Peritonitis

PresentationSymptoms according to location of the affected diverticulum • Left lower quadrant pain 70% • Pain is crampy and associated with changed bowel habit• Other symptoms:

• Nausea and Vomiting. • Constipation.• Diarrhea.• Flatulence.• Bloating.

• Asymptomatic • Mimic acute appendicitis if lower right quadrant

Signs revealed on physical examination:• Localized abdominal tenderness• Tender palpable mass• Abdomen may be distended• Unremarkable signs in patient on Corticosteroids

Management of Diverticular bleeding• 17-40% of lower GI bleeding (most common cause)• Most is self-limited in 80% • Lactated Ringer • Packed RBCs

• In severe bleeding → resuscitative measures • Bowel preparation → Colonoscopy • Endoscopic therapeutic measures for lesion detected by

colonoscopy• Epinephrine or electrocautery treatment • Endoclips or band ligation

• For lesion not detected by Colonoscopy• Radionuclide imaging• Arteriography

• Treatment modalities • Embolization (effectively controls hemorrhage in 76% to

100%)• Injection vasopressin (seldom used clinically because

rebleeding rate is 50%)

Management of Diverticular bleeding

• Surgery • Directed segmental resection• Subtotal colectomy• uncontrolled, massive, nonlocalized lower

GI bleeding refractory to other interventions

• In patients with 2 or more episodes of diverticular hemorrhage, elective resection should be considered