Diverticulitis-an update

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Diverticulitis-an update

• Dr Bernard Stacey
• Consultant Gastroenterologist
• SUHT

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Aims

• The natural history of diverticular disease
• Medical treatment for the majority of patients
  with diverticular disease?
• Who needs surgery?
• Is age a problem?
• What about patients with chronic LIF pain and
  associated diverticular disease?

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Diverticulae

• Colonic diverticula are mucosal outpouchings
  through the large bowel wall
• Often accompanied by structural changes
  (elastosis of the taenia coli, muscular
  thickening, and mucosal folding)
• Usually multiple
• Most frequently in the sigmoid colon

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Geography/Diet

• Diverticulosis is common in resource-rich
  countries
• There is a lower prevalence of diverticulosis in
  Western vegetarians consuming a diet high in
  fibre
• Diverticulosis is almost unknown in rural Africa
  and Asia

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Spectrum of presentation

• Majority of people with colonic diverticula are
  asymptomatic
• Diverticulosis
• 20 develop symptoms at some point
• Diverticular disease
• When diverticulum becomes acutely inflamed
• Acute diverticulitis

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Complex Colonic Diverticular Disease
Jacobs D. N Engl J Med 20073572057-2066
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Complications

• Complications of diverticular disease
• perforation
• obstruction
• haemorrhage
• fistula formation
• are each seen in about 5 of people with colonic
  diverticula when followed up for 1030 years
• UK incidence of perforation is 4 cases/100,000
  people a year, leading to approximately 2000
  cases annually

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Prevalence of Diverticulosis

• 5 to 10 before age 50
• 30 after age of 50
• 50 over age70
• 66 over age 85

Natural history of diverticular disease of the
colonParks TG
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Hinchey Classification Scheme
Hinchey 1 - peri-diverticular abscess within the
mesocolon Hinchey II - distant (pelvic,
retroperitoneal) abscess Hinchey III -
generalized purulent peritonitis Hinchey IV
generalised faecal peritonitis
Jacobs D. N Engl J Med 20073572057-2066
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How to treat?

• If can tolerate fluids and have no peritonitis
• Fluids or Low residue liquid diet
• Pain relief
• Antibiotics (7-10 days) of oral broad spectrum
  antimicrobial therapy ciprofloxacin and
  metronidazole
• Need imaging of bowel to exclude other pathology
  (10)
• Management can be repeated
• Consider hospital if unable to tolerate fluids,
  cannot manage pain, fails to improve or has
  complicated diverticulitis

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Acute hospital admission

• Drip (/- suck)
• IV antibiotics
• CT
• high sensitivity 93-97
• specificity 100
• Barium enema / colonoscopy / flex sig to check
  for other pathology (avoid for 6 weeks)

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CT Scans of the Colon in Four Patients with
Diverticulitis of Varying Severity
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Who needs operation?

• Hinchey I - conservative
• Hinchey II distal or large abscess gt 4cm CT
  drainage
• Less than 10 of Hinchey I and II need operation
• Hinchey III usually operation
• Hinchey IV always operation

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Outcome at presentation Hinchey stage

• Risk of death
• lt5 for most patients with stage 1 or 2
• 13 for stage 3
• 43 for stage 4

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Does one or more attacks predict further or more
serious ones?

• NO
• gt50 of patients presenting to hospital with
  complicated diverticular disease - first
  presentation
• 70 of these will have perforation

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What happens after first attack?

• Recurrent diverticulitis is observed in 742
• 2551 patients followed up over 9 years 13
  recurrent attacks and 7 required surgery
• 10 recurrence in 1st year and 3 each year
  afterwards

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Medical treatment

• Fibre
• Lancet 1977 Broadribb
• 18 patients single randomised controlled trial
  with crossover. Stopped at 3 months
• Caused a reduction in symptoms!
• Probiotics
• 2 small trials
• Longer remission
• 5ASA
• 3 trials
• Reduce peridiverticular inflammation

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Patients over 75 years old
Age lt75 Age gt 75
No of colectomies 9458 2532
In hospital death 4 13
1 year mortality 4 18
Discharged home 61 27
Median stay 10 days 13 days
1999-2001 data from California Parikh and Ko ASCRS 2008 1999-2001 data from California Parikh and Ko ASCRS 2008 1999-2001 data from California Parikh and Ko ASCRS 2008
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Disease progression

• Inflammation will develop in 1025 of people
  with diverticula at some point
• Even after successful medical treatment of acute
  diverticulitis, almost two thirds of people
  suffer recurrent pain in the lower abdomen

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Spectrum of symptoms with IBS

• People with uncomplicated diverticular disease
  may report
• abdominal pain (principally colicky left iliac
  fossa pain)
• bloating
• altered bowel habit
• may have mild left iliac fossa tenderness on
  examination.

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To operate or not?

• Decreasing morbidity and mortality with
  laparoscopic colonic surgery
• Some cases of chronic pain and recurrent attacks
  do extremely well
• Need to earn their surgery and understand the
  risks

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Summary

• Most people in the Western World will develop
  diverticulae
• Most will remain asymptomatic
• The most serious complication is faecal
  perforation (43 mortality) most likely to
  occur at first attack
• After first attack of complicated diverticulitis
  10 recur in the first year then 3 per year

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Summary

• If can tolerate fluids
• Treat at home with fluids, antibiotics for 7-10
  days and then put on fybogel, probiotics and ?ASA
• If cannot manage pain relief or fluids, or
  patient sick admit
• 2 attacks no longer means surgery
• Tailor on-going management plan according to
  patient needs

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Conclusion

• Perforated diverticulitis kills but we cannot
  predict the group in whom this occurs
• Surgery kills must think carefully before doing
  surgery