Transcript Diverticulitis, Diverticulosis, Pancreas and Gallballer

Diverticulosis &
Diverticulitis
Victor Politi, M.D., FACP
Medical Director, SVCMC School of Allied Health
Physician Assistant Program
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Diverticulum – A diverticulum is a pouch or a pocketlike opening in the bowel wall, usually in the colon.
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The pouch is formed by the hernia of superficial layers of
the colon through the weak points in the bowel wall a small
pouch in the colon that bulges outward through a weak spot
The occurrence of a diverticulum is known as
diverticulosis
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About 10 percent of Americans over the age of
40 have diverticulosis.
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The condition becomes more common as people
age.
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About half of all people over the age of 60 have
diverticulosis.
Normal
Abnormal
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When the pouches become infected or inflamed,
the condition is called diverticulitis.
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This happens in 10 to 25 percent of people with
diverticulosis.
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Diverticulosis and diverticulitis are also called
diverticular disease
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Diverticulitis can occur anywhere in the
gastrointestinal tract
most commonly observed in the colon.
 Small bowel diverticulitis is far less common than
colonic diverticulitis.
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Asymptomatic diverticulosis is a common
condition, but few patients with diverticula
develop symptomatic diverticulitis.
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Diverticulitis -generally considered a disease of
the elderly population but
as many as 20% of patients with diverticulitis are
younger than 50 years.
 Diverticulitis may be a more severe illness when
observed in younger patients
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painful diverticular disease
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The diverticula are usually harmless and do not
cause problems in 70-80% of patients
Some persons may develop cramps, bloating,
and irregular bowel movements without fever or
other signs of infection.
These patients are believed to have "painful
diverticular disease”
painful diverticular disease
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A cause-effect relationship between these
symptoms and diverticulosis has not been
established.
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patients usually treated with high fiber diet plus
medications to relieve spasms
Some of these patients may not respond to
medical therapy.
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Use of surgery in such patients in the absence of
giant diverticula and or any of its complications is
controversial
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In about 25% of patients with painful
diverticular disease - develops in the bowel wall
through the diverticulum leading to infection
and inflammation around the colon.
This complication is known as diverticulitis.
The infection usually stays localized, but can
spread into the abdomen causing severe
diverticulitis.
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Senior citizens are prone to the more serious form,
especially if they are taking medications that increase
susceptibility to infection.
Patients develop pain in the lower, left part of the
abdomen, along with fever and other signs of infection.
A majority of patients report nausea, vomiting,
distended abdomen or recent "constipation".
Acute inflammation in the colon may also affect
adjacent organs like the bladder, causing painful or
increased urination
What causes diverticular disease?
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Diverticulitis occurs when diverticula become
infected or inflamed.
It is unclear as to what causes the infection.
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It may begin when stool or bacteria are caught in the
diverticula.
An attack of diverticulitis can develop suddenly
and without warning
What causes diverticular disease?
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The etiology of diverticulitis remains unclear,
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A low-fiber diet is considered a predisposing factor
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Diverticular disease is common in developed or industrialized
countries--particularly the United States, England, and
Australia--where low-fiber diets are common.
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The disease is rare in countries of Asia and Africa, where
people eat high-fiber vegetable diets.
The low-fiber diet connection
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Fiber is the part of fruits, vegetables, and grains
that the body cannot digest.
Some fiber dissolves easily in water (soluble fiber). It
takes on a soft, jelly-like texture in the intestines.
 Some fiber passes almost unchanged through the
intestines (insoluble fiber).
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The low-fiber diet connection
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Both kinds of fiber help make stools soft and
easy to pass. Fiber also prevents constipation
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Constipation makes the muscles strain to move
stool that is too hard.
It is the main cause of increased pressure in the
colon.
 This excess pressure might cause the weak spots in
the colon to bulge out and become diverticula
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Other Possible Predisposing Factors
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Aging
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causes changes in collagen structure- may lead to
weakening of the colonic wall.
Colonic motility disorders
Long term Corticosteroid or NSAID use
Genetics
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believed to play a role, Asian people tend to have a
predominance of right-sided diverticula, while
Western people tend to have left-sided disease
Diverticulosis Symptoms
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Most people with diverticulosis do not have any
discomfort or symptoms.
However, symptoms may include mild cramps,
bloating, and constipation.
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Other diseases such as irritable bowel syndrome
(IBS) and stomach ulcers cause similar problems, so
these symptoms do not always mean a person has
diverticulosis.
Diverticulitis
Symptoms
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Most common symptom -abdominal pain
Most common sign- tenderness around the left side of
the lower abdomen
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If infection is the cause, fever, nausea, vomiting, chills,
cramping, and constipation may occur as well.
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The severity of symptoms depends on the extent of
the infection and complications
Diverticulitis Complications
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Diverticulitis can lead to
Abscess
 Diverticular Hemorrhage
 Intestinal fistula
 Intestinal perforation
 Intestinal obstruction
 Sepsis and septic shock
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Diverticulitis Complications
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Diverticular Hemorrhage
rare complication 5% of cases
 sudden in onset, painless and substantial -the result
of a weakened blood vessel in a diverticulum
bursting
 Bleeding is usually not seen during an acute episode
of acute diverticulitis - Diverticula bleed when they
are otherwise healthy
 bleeding stops spontaneously in most patients.
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Diverticulitis Complications
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Diverticular Hemorrhage
In some cases, the bleeding may continue
intermittently for a few hours to a few days before
resolving
 Chronic intermittent bleeding due to diverticulosis is
unusual
 As many as 80% patients do not have any recurrence
of bleeding.
 Surgery may be needed in 50% of cases of massive
diverticular bleeding.
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Diverticulitis Complications
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Infection
Treated with antibiotics
 usually clears up after a few days of treatment
 Rest the Gut
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Abscess 
An abscess is an infected area with pus that may
cause swelling and destroy tissue
Diverticulitis Complications
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Perforation
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Sometimes the infected diverticula may develop small holes
(perforations)
The perforations allow pus to leak out of the colon into the
abdominal area
If the abscess is small and remains in the colon, it may clear
up after treatment with antibiotics.
If the abscess does not clear up with antibiotics, it may
require drainage (percutaneous catheter drainage)
Sometimes surgery is needed to clean the abscess and, if
necessary, remove part of the colon
Diverticulitis Complications
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Peritonitis- (an infection of the abdominal cavity)
A large abscess can become a serious problem if the
infection leaks out and contaminates areas outside
the colon.
 Infection that spreads into the abdominal cavity is
called peritonitis.
 Peritonitis requires immediate surgery to clean the
abdominal cavity and remove the damaged part of
the colon.
 Without surgery, peritonitis can be fatal.
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Diverticulitis Complications
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Fistula
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Abnormal connection of tissue between two organs or
between an organ and the skin
When damaged tissues come into contact with each other
during infection, they sometimes stick together. If they heal
that way, a fistula forms
When diverticulitis-related infection spreads outside the
colon, the colon's tissue may stick to nearby tissues.
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The organs usually involved are the bladder, small intestine,
and skin.
Diverticulitis Complications
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Fistula
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The most common type of fistula occurs between the
bladder and the colon. Colovesicular fistula (colon to urinary
bladder).
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This is observed almost exclusively in men
Also seen in women following hysterectomy
This type of fistula can result in a severe, long-lasting infection of the
urinary tract.
Can be corrected with surgery to remove the fistula and the affected
part of the colon
Colovaginal and colocutaneous fistulae are much less
common
Diverticulitis Complications
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Intestinal Obstruction
The scarring caused by infection may cause partial or
total blockage of the large intestine.
 When this happens, the colon is unable to move
bowel contents normally.
 If the obstruction totally blocks the intestine,
emergency surgery is necessary
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The diagnosis of acute diverticulitis is often
made on the basis of history and physical
examination, followed by confirmatory
laboratory and radiologic tests
diagnosing diverticular disease
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medical history
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physical exam
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digital rectal exam, occult blood, bloodwork,
diagnostic tests
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bowel habits, symptoms, pain, diet, medications
Imaging studies, endoscopy
Most people do not have symptoms so diverticulosis is
often found through tests ordered for another ailment
History/Physical
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The clinical presentation of diverticulitis depends
on:
 location
 severity of the underlying inflammatory process
 and on whether complications are present
History/Physical
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Frequent Symptoms of acute diverticulitis - abdominal
pain and fever
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Usually, pain is severe, abrupt in onset, localized to the left
lower abdominal quadrant, and worsens steadily over time.
Sometimes referred to as left-sided appendicitis, diverticulitis
is often accompanied by anorexia, nausea, and vomiting.
Altered bowel habit, especially constipation, is common
History/Physical
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Because diverticula and diverticulitis can develop
anywhere in the gastrointestinal tract, symptoms
may mimic multiple conditions.
History/Physical
Diverticulitis in the transverse colon may mimic
peptic ulcer disease, pancreatitis, or cholecystitis.
 Diverticulitis in the right colon may be confused
with acute appendicitis.
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With disease progression, localized abscess and
phlegmonous formation may occur.
Systemic signs of infection, such as fever and
leukocytosis, become more pronounced.
History/Physical
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Localized peritonitis may lead to direct and rebound
tenderness over the involved area.
On physical examination, rebound tenderness is
generally most pronounced in the left lower abdominal
quadrant.
The abdomen may become distended and tympanic to
percussion.
Bowel sounds may become diminished or absent.
Sometimes, a mass may be felt at the site of the
inflammation.
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This may be apparent not only on abdominal palpation but
also on pelvic or rectal examination
History/Physical
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Elderly patients and those taking corticosteroids
may have unremarkable findings on physical
examination, even in the presence of severe
diverticulitis.
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Such patients must be approached with a high index
of suspicion, in order to avoid a significant delay in
arriving at the correct diagnosis.
History/Physical
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Hematochezia, or bright red blood per rectum,
is not a symptom of diverticulitis, although
occult blood in the stool is present in
approximately 25% of patients with
diverticulitis.
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When hematochezia is noted, other causes (eg,
hemorrhoids, neoplastic disease, colitis, vascular
ectasias, arterial bleeding from diverticulosis) should
be considered
History/Physical
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If a colovesicular fistula is present, urinary tract
symptoms, including dysuria, urgency,
pneumaturia, fecaluria, and recurrent urinary
tract infections, may be prominent.
Patients with colovaginal fistulas may present
with a purulent vaginal discharge.
Colovesical Fistula
History/Physical
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Leg pain, possibly associated with thigh abscess,
and leg emphysema secondary to retroperitoneal
perforation from diverticulitis have been
reported.
Lab Studies
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Routine laboratory data are important to
confirm the presence of infection and to
exclude other possible etiologies of abdominal
pain.
Lab Studies
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CBC -identifies leukocytosis and/or a left shift.
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However, 20-40% of patients may have a white
blood cell count in the reference range, particularly
patients who are immunocompromised and elderly.
Chemistries
Liver function tests and amylase/lipase may help
exclude other causes of abdominal pain, especially in
atypical presentations or generalized peritonitis.
 Serum electrolyte findings can help detect important
abnormalities in cases of sepsis or GI bleeding.
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Lab Studies
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Blood cultures should be obtained prior to
administration of empiric antimicrobial therapy.
Urinalysis and urine cultures
to identify urinary tract infection
 In the presence of a colovesicular fistula
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urinary cultures may reveal a polymicrobial infection
Imaging Studies
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X-rays to make sure the colon has not
perforated
CT scan with contrast of the abdomen/pelvis if
the diagnosis is unclear
Flexible Sigmoidoscopy and Barium enema only
after symptoms are improved (if these tests are
done too early, they can cause a colon
perforation)
Imaging Studies
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On plain radiograph, an abdominal series with
flat and upright abdominal films may show an
obstruction, ileus, or free air, indicating visceral
perforation. Radiopaque gallbladder or renal
stones may also be observed
Imaging Studies
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CT scan of the abdomen is considered the
optimal method of investigation in patients
suspected of acute diverticulitis.
CT scan is also very helpful in determining the
extent of complications of the disease
Procedures
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Endoscopy is not usually used in the evaluation
of acute episodes of diverticulitis because of
the possibility of perforation and subsequent
development of peritonitis
Treatment of diverticulitis
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Treatment for diverticulitis focuses on:
clearing up the infection and inflammation
 resting the colon (bed rest,liquid diet, pain meds as
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needed)
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preventing or minimizing complications
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An attack of diverticulitis without complications
may respond to antibiotics within a few days if
treated early.
Treatment of diverticulitis
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Dependent on:
clinical presentation
 the location of the lesion
 severity of underlying inflammatory process
 comorbid factors.
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Treatment of diverticulitis
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In mild cases, the diagnosis of diverticulitis can
be made with confidence on the basis of clinical
examination findings.
These patients are not very ill and are able to tolerate
food and oral fluids.
 Patients with mild diverticulitis can be started on an
outpatient treatment regimen.
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Treatment of diverticulitis
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Outpatient treatment consists of
a liquid diet
 7-10 days of oral broad-spectrum antimicrobial
therapy
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which covers anaerobic microorganisms such as
Bacteroides fragilis and Peptostreptococcus and Clostridium
organisms, as well as aerobic microorganisms such as
Escherichia coli and Klebsiella, Proteus, Streptococcus, and
Enterobacter organisms.
One typical antibiotic regimen is a combination of
ciprofloxacin and metronidazole
Treatment of diverticulitis
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Hospitalization is required if:
patients are unable to tolerate oral hydration
 if outpatient therapy fails
 if notable fever and/or peritoneal signs develop
 if pain is severe enough to require narcotic analgesia
 or if patients have a chronic underlying medical
condition.
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Treatment of diverticulitis
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These patients have moderate-to-severe
diverticulitis;
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do not provide anything by mouth.
Initiate intravenous fluid hydration and start
broad-spectrum intravenous antibiotic coverage.
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The typical standard triple antibiotic regimen in
these situations is a combination of ampicillin,
gentamicin, and metronidazole.
Treatment of diverticulitis
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Pain management is also important.
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Meperidine is an appropriate choice if narcotics are
required. Avoid morphine sulfate because it can
cause colonic spasm.
Once the acute episode has resolved, instruct
the patient to maintain a high-fiber diet and to
undergo elective colonoscopy
Treatment of diverticulitis
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Surgical treatment is usually necessary in only
20-30% of patients with acute diverticulitis
Treatment of diverticulitis
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When is surgery necessary?
If attacks are severe or frequent
 complications of a fistula or intestinal obstruction
 emergency surgery may be required for -a large
abscess, perforation, peritonitis, or continued
bleeding
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Treatment of diverticulitis
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Emergency surgery usually involves two operations.
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The first clears the infected abdominal cavity/removes part
of the colon
The second rejoins the ends of the colon
Due to infection/obstruction, it is not safe to rejoin the
colon during the first operation.
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Instead, a temporary hole, or stoma, in the abdomen is made
The end of the colon is connected to the hole, a procedure
called a colostomy, to allow normal eating and bowel
movements.
Further Outpatient Management
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In the elective setting, patient evaluation should be
conducted after the resolution of an episode of acute
diverticulitis.
The colon requires full evaluation with colonoscopy or
barium enema to establish the extent of disease and to
rule out lesions such as polyps or carcinoma.
Diverticulitis may lead to stricture formation that can
have the appearance of carcinoma; a biopsy of such a
lesion should be performed
Dietary Management
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Administer nothing by mouth in episodes of
moderate-to-severe acute diverticulitis.
In mild episodes, a clear liquid diet is advised.
Long-term management includes a high-fiber,
low-fat, and low-beef diet.
Dietary Management
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Increasing the amount of fiber in the diet may
reduce symptoms of diverticulosis and prevent
complications such as diverticulitis.
Fiber keeps stool soft and lowers pressure inside the
colon so that bowel contents can move through
easily.
 The American Dietetic Association recommends 20
to 35 grams of fiber each day.
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Dietary Management
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Fiber product –
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Citrucel or Metamucil once a day. These products
are mixed with water and provide about 2 to 3.5
grams of fiber per tablespoon, mixed with 8 ounces
of water.
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Diverticulosis is a very common, and usually a
very benign condition
Complications occur only in a minority of
patients, and most of them get well with medical
treatment alone without any need for surgery