Diverticular Disease Christopher Gross Gillian Lieberman, MD - PowerPoint PPT Presentation

Diverticular Disease Christopher Gross Gillian Lieberman, MD March 2008

Goals � Definitions � Epidemiology � Anatomy � Pathophysiology � Symptoms � Menu of Diagnostic Modalities

Definitions � Diverticulum – sac-like protrusion of the colonic wall that consists of mucosa, submucosa, serosa � Diverticulosis – the presence of diverticula, often an incidental finding � Diverticulitis – inflammation resulting from a perforation of a diverticulum � Diverticular Hemorrhage – Diverticular bleeding usually not associated with diverticulitis

Epidemiology � Age : � Affects <5% before 40yo � 30% at 60yo � 65% at 80yo � 20% of those present with sxs � Risk factors : � “disease of Western Civilization” � low fiber � constipation � obesity, lack of physical activity � NSAIDs � smoking

Anatomy � Pseudodiverticula – Herniations of mucosa and submucosa covered by serosa where vasa rectae penetrate the circular muscle layer � Between each side of the mesenteric taenia, and on one side of antimesenteric taeniae www.accesssurgery.com “Current Surgical Diagnosis and Treatment” http://www.meddean.luc.edu/

Pathophysiology � 95% of diverticuli occur in the sigmoid � In Asians, 70% present as R-sided pain � Laplace’s law: (P=T/r), sigmoid has the smallest diameter and largest pressures � Segmentation exaggerated � increase in intralumenal P www.webmd.com

Patient: KB 51 yo M who presents to ED with left lower abdominal pain and anorexia.

History of Present Illness � LLQ pain x 3wks; +distension and pressure � PCP Rx Levofloxacin + Ciprofloxacin 2 wks prior � No Nausea/Vomiting � +Bowel Movements, no BRPRP, no diarrhea � Afebrile, HR: 96, BP: 156/89

More information . . . � PMH � HTN � Hyperlipidemia � ?Sleep apnea � ?GERD � Hiatal Hernia � Medications � HCTZ 25mg QD � Atenolol 25mg QD

Physical Exam � Significant findings: � tender LLQ to palpation � Distended, +rebound � Labs � Electrolytes, LFTs nl � CBC: 16.0\___/336 /44.3\

Differential DDx: Differential Diagnosis Appendicitis, cholecystitis Ischemic colitis Colorectal CA Mesenteric infarction Cystitis Ovarian torsion IBD PID, endometriosis IBS Renal disease Incarcerated Hernia SBO, LBO Colorectal CA can have microperforations and become 2 o infected � Follow-up colonoscopy is recommended in 6-8wks in a suspicious CT. �

Clinical Presentation Clinical Incidence Presentation LLQ pain 93-100% Fever, chills 57-100% Leukocytosis 69-83% Nausea 20% /Vomiting Mass Constipation Diarrhea Urinary Sxs

What should we order for our patient?

Menu of Imaging � Goals: establish Dx and demonstrate the extent and severity of diverticulitis; ?complications � Menu: � Barium Enema –largely outdated � CT —test of choice � US —in pregnancy � Can be used in initial eval of lower abd pain, esp w/ females � Will see hyperechogenicity surrounding bowel wall

Companion Pt 1: Diverticulosis on Barium Enema � Double contrast used to be gold standard � Sensitivity: 82% � Specificity: 81% � Shows divertics, with sigmoid narrowing, extravasation � (+) Provided info on presence and degree of diverticula � ( - ) Cannot discern clinical Luminal relevance, missed Dx in 33% narrowing www.radiologychannel.net/diverticuliti � C/I in cases of suspected perforation and emergencies

CT: Test of Choice � Triple contrast (IV, PO, rectal) now standard � Sensitivity– 85-97% � (+) Can quantify diverticulitis to direct management, see presence of complications CT based scoring system for diverticulitis Management Stage 0 Mural thickening and diverticulae Conservative Stage 1 Abscess/phlegmon <3cm in diam Conservative in low risk patients Stage 2 Abscess 5-15cm in diam CT-guided percutaneous drainage or Surgery Stage 3 Abscess beyond the confines of pelvis Surgery Stage 4 Fecal peritonitis Surgery

Companion Pt 2: CT Manifestations of Diverticulitis � Pericolic fat infiltration (98%) Wall thickening � Thickened fascia, wall thickening >4mm (78.9%) � Muscular Hypertrophy (26.3%) � “Arrowhead” sign (23.7%) � Other signs of complications � Abscess (35%) Fat stranding Intramural sinus tract (with air or contrast) with � thickened wall � Fistulas http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow228arr.jp � Perforation � Obstruction

Companion Pt 3 + 4: Percutaneous Drainage of Diverticular Abscess 5cm abscess, Stage 2 Pigtail catheter Thickened walls, sigmoid abscess http://www.emedicine.com/radio/images/336139 ‐ 367320 ‐ 6366.jpg Halligan, et al. “Imaging Diverticular Disease” • Percutaneous Drainage: Seldenger Technique with 12 French gauge locking pigtail catheter

What does our patient’s CT show?

Our Pt KB: Pelvic Fistula on Pelvic CT Small sinus tract 6cm Enteroenteric fistula PACS small sinus tract in pelvis communicating w/ Colocolonic fistula rectosigmoid colon, dilated sigmoid

Companion Pt 5 + 6: Fistulas on CT and Abd Plain Film � 2-10% of cases: Colovesical > colovaginal > coloenteric > colouteral Air, stool, oral contrast in bladder Air in bladder http://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html http://myweb.lsbu.ac.uk/dirt/museum/margaret/838-2454a-1480410.jpg

Companion Pt 7: Perforation on Abd CT • Mortality for Stage III is 13% and Stage IV is 43% Extraluminal air Stollman, et al. “Diverticular Disease of the Colon”

Treatment Recommendations CT scoring Management Stage 0 Conservative– Flagyl +/- Cipro; hospitalize if severe Stage 1 Conservative Stage 2 Drainage or Surgery Stage 3 Surgery (Sigmoid resection with 1 o anastamosis) Stage 4 Surgery (Hartmann procedure) � Elective Surgery: 6-8wks later � One episode of complicated � 2 confirmed episodes that require hospitalization � Immunocompromised

Our Pt KB: Hospital Course � Hospital course of Amp, Levo, Flagyl � Pt was scheduled for a hemicolectomy � Found to have rectosigmoid stricture during ex-lap � Low anterior resection (L hemicolectomy) with 1 o anastamosis to the rectum

Conclusion � Diverticulosis vs. diverticulitis � Initial Presentation of Diverticulitis � Diagnostic Menu: know the CT manifestations and their associated treatments

Thanks to: • Dr. Gillian Lieberman • Dr. Andrew Hines-Peralta • Dr. James Kang

Works Cited Boulos PB “Complicated Diverticulitis” Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):649- � 662. Review Buchanan GN, Kenefick NJ, Cohen CR. “Diverticulitis”. Best Pract Res Clin Gastroenterol. 2002 � Aug;16(4):635-47. Review Ferzoco LB, Raptopofhdfulos V, Silen W. “Acute diverticulitis”. N Engl J Med. 1998 May � 21;338(21):1521-6. Review. Halligan S, Saunders B. “Imaging Diverticular Disease”. Best Pract Res Clin Gastroenterol. 2002 � Aug;16(4):595-610. Review Johnson CD, Baker M, Rice R, Silverman P, Thompson W. “Diagnosis of Acute Colonic � Diverticulitis: Comparison of Barium Enema and CT” AJR 1987 March; 148: 541-546 Makela J, Vuolio S, Kiviniemi H, Laitinen S. “Natural history of diverticular disease: when to � operate? “Dis Colon Rectum. 1998 Dec;41(12):1523-8. Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon � and Rectal Surgeons. “Practice parameters for sigmoid diverticulitis”. Dis Colon Rectum 2006 Jul;49(7):939-44. Salzman H, Lillie D. “Diverticular Disease: Diagnosis and Treatment” American Family Physician. � 2005 Oct 1; 72(7): 1229-1233 Shen SH, Chen JD, Tiu CM, Chou YH, Chang CY, Yu C. “Colonic diverticulitis diagnosed by � computed tomography in the ED”. Am J Emerg Med 2002;20:552. Stollman N, Raskin J. “Diverticular Disease of the Colon”. The Lancet. 2004 Feb 21; 363: 631- � 639