Large bowel

Anatomy recall
 Diverticular Disease of the Colon

Background
Diverticula are sacklike protrusion of the colonic
wall, varying in size from:
a few millimeter to
several centimeters

True diverticular contain all layers of the colon

wall and are believed to be congenital

Remember
They are very uncommon in the colon
 Diverticular Disease of the Colon
Background
False or pseudodiverticula represent herniations of the
mucosa and submucosa through the circular muscle of
the bowel wall

The term diverticulosis simply indicates the presence of

multiple diverticula of the colon

Unless otherwise stated, the term diverticula refers to the

predominant lesion, namely, colonic pseudodiverticula
 Diverticular Disease of the Colon
Prevalence
The prevalence of diverticula disease in the general
population ranges between 35% and 50% as
estimated by large autopsy and radiographic series

Prevalence directly correlates with age

estimated to be less 5% at age 40
increasing to 30% by age 60, and
as high as 65% by age 85
 Diverticular Disease of the Colon

Prevalence
Geographically, diverticular disease is much more
common in the Unites states and Western Europe
than in other less industrialized regions such as:
Africa
South America and
Asia
 Diverticular Disease of the Colon

Prevalence
Although diet is thought to contribute significantly to
the development of diverticular disease, the
complete etiology is likely to involved other, as
yet unrecognized, factors

For example, diverticular disease in Asian

population is predominantly to the right colon,
indistinct contrast to the left-sided predilection
observed in Western civilization
 Diverticular Disease of the Colon

Prevalence
Such variation in the anatomic distribution of
diverticula among civilizations might suggest that
factors other than diet alone
 Diverticular Disease of the Colon

Mechanical Factors
Clinical studies within 30 years have implicated low fiber diets as a prominent etiologic factor in the development of diverticular disease
 Diverticular Disease of the Colon

Anatomic features
Diverticula tend to develop at specific points in the
circumference of the colon

This localization is determined, in part, by the

anatomic relationship between the colonic
musculature and its nutrient blood supply
 Diverticular Disease of the Colon
Anatomic features
Diverticula form at so-called weak points where the
nutrient blood vessels (vasa recta) penetrate the
circular muscle layer en route to the mucosa
 Diverticular Disease of the Colon
Mechanical Factors
Diverticular therefore are usually located between
the single mesenteric teniae and either of the two
antimesenteric teniae
 Diverticular Disease of the Colon
Mechanical Factors
In distribution of diverticular throughout the colon also tends to follow a
pattern

►The overwhelming majority of diverticulosis will have involvement of the

sigmoid colon (90% -95%)

Conversely, only a small number of patients (2%-10%) will have disease

confined to the right colon

►Solitary diverticula occur most commonly in the cecum

 Diverticular Disease of the Colon

Cecum 2 %
Ascending colon 2 %
Transverse colon 1 %
Descending colon 1 %
Sigmoid colon 94%
 Diverticular Disease of the Colon
Natural history
► Most patients with diverticulosis remain asymptomatic throughout their life time

► It estimated that between 10% and 25% of patients eventually develop signs and
symptoms of diverticulitis

► Another 15% present with diverticular hemorrhage

 Diverticular Disease of the Colon
Natural history
►As in most conditions, the prognosis of any one
episode of:

* bleeding or
* inflammation
varies according to the ▼

1) patient’s general health and

2) severity of the underlying disease process
 Diverticular Disease of the Colon

Natural history
►Patients with mild diverticulitis can be treated
conservatively with excellent results

While patients with free intra-abdominal perforation

of a diverticulum require emergent operation and
can be expected to incur a 20% mortality
 Diverticular Disease of the Colon
Natural history
After the first episode of diverticulitis, approximately
one third of patients will sustain a second attack,
usually within to 5 years

Another 30% to 40% will suffer from intermittent

symptoms of: ▼
discomfort and
crampy abdominal pain
without requiring hospitalization
 Diverticular Disease of the Colon

Natural history
The prognosis is worse after a second attack

The morbidity and the mortality from the recurrent attack are
also higher than that associated with an initial episode
 Diverticular Disease of the Colon

Natural history
► Complication such as:
abscess formation or
fistulization
develop in approximately 20% of patients after a
single attack of diverticulitis

While the complication rate approaches 60% in patients

who have had previous episodes
 Diverticular Disease of the Colon

Natural history
Age:
Because the diverticulosis is an acquired disease,
the incidence of which clearly increases with
age
 Diverticular Disease of the Colon

Complications of Diverticulosis
Hemorrhage
Diverticular disease is the most common cause of massive
lower gastrointestinal bleeding in adults

Although, overall, colon carcinoma is the most common

source of gastrointestinal blood loss, such bleeding, is usually
small in volume, often being detected only as occult blood on
chemical testing
 Diverticular Disease of the Colon

Hemorrhage
Incidence and Etiology
Bleeding can be expected to develop in 15% of patients
with diverticulosis

and before the use of:

angiography and
emergency colonoscopy
diverticula were thought to account for up to 90% of
significant lower intestinal hemorrhage
 Diverticular Disease of the Colon

Hemorrhage
Incidence and Etiology
With the advent of improved localization techniques,
angiodysplastic lesions, also known as
arteriovenous malformation
have been implicated with increasing
frequency as a cause of colonic bleeding
 Diverticular Disease of the Colon
Hemorrhage
Incidence and Etiology
massive colonic bleeding is due to:
Diverticulosis: 30% to 50%
Angiodysplasia: 20% to 30%

The remaining causes include:

colonic neoplasms
inflammatory bowel disease
ishemic colitis and
rare congenital lesions
Hemorrhage
Incidence and Etiology
Diverticular hemorrhage arises from the right colon in 70% to
90% of patients

Approximately 70% of patients with diverticular hemorrhage will

stop bleeding spontaneously, often before presentation at the
hospital

The risk of rebleeding is only 30%, but it increases to 50% after

a second episode of hemorrhage
 Diverticular Disease of the Colon
Hemorrhage
Clinical features
Patients often described intermittent, sporadic passage of:
bright red or
marron blood per rectum

Fifty percent of patients will give a history of previous

episode of colonic hemorrhage
 Diverticular Disease of the Colon

Hemorrhage
Clinical features
Usually:
abdominal pain or
discomfort is absent and
physical examination is unremarkable
 Diverticular Disease of the Colon

Hemorrhage
Clinical features
► 50% of patients with diverticular hemorrhage
present with massive, exsanguinating hemorrhage

► Such patients demand:

immediate resuscitation and
therapeutic intravenous
 Diverticular Disease of the Colon

Hemorrhage
Clinical features
► The overwhelming majority of these patients are
elderly, usually in their seventh or eighth decade

Consequently 70% of these patients have serious

comorbid diseases
 Diverticular Disease of the Colon
Hemorrhage
Diagnosis
The first step in the management of any patient with
massive gastrointestinal hemorrhage is resuscitation

►Monitoring should be instituted rapidly, as for any

patient with the potential for hypovolemic shock
 Diverticular Disease of the Colon
Hemorrhage
Diagnosis
The passage of a nasogastric tube helps exclude an
upper gastrointestinal source of bleeding

Resuscitation should commence before any further

diagnostic maneuvers are undertaken
 Hemorrhage
Diagnosis
►All patients with massive lower gastrointestinal hemorrhage should
undergo proctoscopy as soon as possible

the main purpose of this examination is to exclude the rectum as the

bleeding source

Although difficult in the face of active hemorrhage, identification of

bleeding from:
hemorrhoids or
other rectal lesions is extremely important
 Diverticular Disease of the Colon

Hemorrhage
Diagnosis
Seventy to 80% of patients will stop bleeding
spontaneously, such patients should undergo
elective evaluation

Continued massive bleeding in a hemodynamically

unstable patients is an indication for emergent
operation
 Diverticular Disease of the Colon

Hemorrhage
Diagnosis
However, in active bleeding patients who maintain relative
hemodynamic stability, attempts at localization of the
bleeding site should be made
 Diverticular Disease of the Colon

Hemorrhage
Diagnosis
► Emergency selective mesenteric arteriography will successfully identify the site of
hemorrhage in 40% to 60% of patients

Another alternative:
► Colonoscopy
► Radioisotop scan
 Diverticular Disease of the Colon

Treatment
Resuscitative measures:
fluid
blood transfusion and
correction of coagulation abnormalities

► Vasopressin (is a potent vasoconstrictor) in intra-

arterial infusion
 Diverticular Disease of the Colon

Treatment
► Transcatheter embolization may be an alternative

► Surgery
Thanks