Diverticular Disease and

Hemorrhoids

Lance T. Uradomo, MD, MPH

Assistant Professor of Medicine
Division of Gastroenterology and Hepatology
University of Maryland School of Medicine
Director of Endoscopy, Baltimore VA Medical Center

Center for Cancer Surveillance and Control Teleconference

Maryland Department of Health & Mental Hygiene
January 21, 2009
1
 Outline

Diverticular Disease
Diverticulosis
Diverticulitis
Diverticular Hemorrhage
Hemorrhoids
Classification
Therapy

2
 Anatomy

Hepatic Splenic
Flexure Flexure
Descending
Transver
se
Ascendi Sigmoid
ng
Cecum
Rectum

Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 3
 Definitions
Diverticula an abnormal pouch or sac
opening from a hollow organ (as the colon
or bladder)
Diverticulosis - the presence of diverticula
in the colon
Diverticulitis - inflammation or infection of a
diverticulum of the colon
Diverticular Disease - a disorder
characterized by diverticulosis or
diverticulitis
2005 Merriam-Webster, Incorporated 4
 Introduction
Diverticula
form at weak
points in the
bowel wall
Often where
vasa recta
vessels
penetrate the
muscle layer
Most common
in left colon
(70-90%)

Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 5
 Epidemiology
Prevalence of Diverticula
Age
< 10% in people under 40 year old
50% to 66% over age 80
Gender

Geography
Western countries
Low prevalence in Asia and Africa

Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125 6

 Pathophysiology of
Diverticula
Associations with diets low in dietary fiber
and high in refined carbohydrates.
Less bulky stools that retain less water and may
alter gastrointestinal transit time;
Increase intracolonic pressure and make
evacuation of the colonic contents more difficult.
Other factors:
physical inactivity, constipation, obesity,
smoking, and treatment with nonsteroidal
antiinflammatory drugs.

Jacobs DO, N Engl J Med 2007;357:2057-66 7

 Symptoms of Diverticulosis

Most are asymptomatic

Some experience crampy pain or
discomfort in the lower abdomen,
bloating, and constipation.

8
 Acute Diverticulitis

Most common complication of

diverticular disease
10-25% of patients

Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125 9

 Pathophysiology of
Diverticulitis

Fecalith
Bacterial flora
Micro or
macro
perforation

Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 10
 Presentation of Acute
Diverticulitis
Symptoms
Left lower quadrant pain
Fever
Leukocytosis
Exam
Abdominal tenderness
Mass
High pitched bowel sounds
Rebound
11
 Diagnostic Tests
Xray Free air, perforation
CT scan
Diverticulu
Thickenin m
g

Jacobs DO, N Engl J Med 2007;357:2057-66 12

 Diagnostic Tests
Colonoscopy and sigmoidoscopy are
typically avoided when acute diverticulitis
is suspected because of the risk of
perforation.

Recommended after approximately 6

weeks, to rule out the presence of other
diseases, such as cancer and inflammatory
bowel disease.

Jacobs DO, N Engl J Med 2007;357:2057-66 13

 Treatment of Uncomplicated
Acute Diverticulitis
Antibiotics

14
Jacobs DO, N Engl J Med 2007;357:2057-66
 Treatment of Uncomplicated
Acute Diverticulitis
Hospitalization
Inability to tolerate oral medications and
liquids
Comorbidities
Pain severe enough to require narcotic
analgesia
Symptoms fail to improve despite
adequate outpatient therapy
Complicated diverticulitis
15
 Complicated Diverticulitis

Abscess
Peritonitis
Obstruction
Fistula formation
Hemorrhage

16
 Treatment of Complicated
Diverticulitis
IV antibiotics
Bowel rest
Analgesia
Percutaneous drainage (CT-guided)
Surgery

17
 Recurrent Diverticulitis
25% will have more than one attack of acute
diverticulitis
Parks et al 1969
Recurrence was more virulent and lead to
recommendation for elective resection after the
second episode in >50year old and after first
episode in younger patients.
More recent data fails to show worse prognosis in
recurrent attacks.
American Society of Colon and Rectal Surgeons:
Decision for elective resection is on a case by
case basis
Sheth et al Am J Gastroenterol 2008; 103: 1550 18
 Diverticular Hemorrhage

Rupture of the vasa recta at the

dome of a diverticulum

Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 19
 Diverticular Hemorrhage

Source proximal to the splenic

flexure in 60%
Mean age 66 year old
Most common cause of life
threatening lower GI bleed (3-5% of
those with diverticulosis)

20
 Diverticular Hemorrhage
Diagnosis
History and Physical Exam
Painless, sometimes mild cramps
Hematochezia (red blood per rectum)
Radionucleotide Imaging
Technetium sulfur colloid. Scans are
obtained shortly after intravenous injection,
looking for evidence of extravasation. 0.1
mL/min
Sensitivity 97%, specificity 83%, and
positive predictive value 94%
21
 Diverticular Hemorrhage
Diagnosis
Colonoscopy
Polyethylene glycol for colon purge
preparation
Sedation
May be therapeutic

http://www.uptodate.com/online/content/images/gast_pix/Bleeding_diverticulum_Endos 22
.jpg
 Diverticular Hemorrhage
Diagnosis
Angiography
Performed by Interventional Radiologist
Bleeding at a rate on 0.5 1mL / min
May be therapeutic

23
 Therapy for Diverticular
Hemorrhage
Spontaneous resolution in
90%
Colonoscopy: Study found
0% versus 53% rebleeding
in colonoscopy vs.
medical treatment
Epinepherine
Cautery
Clips

Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82

Browder W. Ann Surg 1986 Nov;204(5):530-6 24
 Therapy for Diverticular
Hemorrhage
Angiography
No purge required
Vasopressin infusion
91% stop bleeding, but
50% rebleed on cessation
of vasopressin
Transcatheter embolization
is more definitive, but is
associated with a up to
20% risk of intestinal
infarction.

Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82

Browder W. Ann Surg 1986 Nov;204(5):530-6 25
 Surgery for Diverticular
Hemorrhage
Frequency of surgery among patients
with severe or massive rectal bleeding
from 24 to 78%.
18 25% of those requiring transfusions
Persistent instability despite
aggressive resuscitation demands
operative intervention and is
necessary
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. 26
Uptodate.com
 Surgery for Diverticular
Hemorrhage
Surgical mortality is approximately 10%

Exploratory laparotomy identifies a

source in 78 percent of patients without
a preoperative diagnosis

Summarized in Young-Fadok T, et al. Colonic diverticular bleeding.

Uptodate.com 27
 Surgery for Diverticular
Hemorrhage
Segmental colectomy
Source of bleeding has been localized
Rebleeding in 0 to 14%
Subtotal colectomy
Patient continues to bleed without an identified site of
bleeding
Morbidity 37%
Mortality rates 11 33%
Blind segmental resection is contraindicated
Rebleeding rate 42%
Morbidity 83%
Mortality 57 %

Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. 28

Uptodate.com
 Recurrence of Diverticular
Hemorrhage
1 year 9%
2 year 10%
3 year 19%
4 year 25%

Longstreth. Am J Gastroenterol 1997; 92: 419 29

 Hemorrhoids

Bleday R. Treatment of hemorrhoids. Uptodate.com 30

 Hemorrhoids
Arise from a plexus of
dilated veins arising
from the superior and
inferior hemorrhoidal
veins.

Submucosal layer in
the lower rectum

External or internal:
below or above the
dentate line.
31
 Classification
Grade I: May bulge into the lumen but do
not extend below the dentate line.
Grade II: Prolapse out of the anal canal with
defecation or with straining but reduce
spontaneously.
Grade III: Prolapse out of the anal canal with
defecation or straining, and require the
patient to reduce them into their normal
position.
Grade IV: Irreducible and may strangulate.
32
 Bleeding

Painless bleeding usually associated with a bowel

movement.
Bright red blood coats the stool at the end of
defecation.
Blood may drip into the toilet or stain toilet paper.
Chronic blood losses from hemorrhages can be
substantial enough to induce iron deficiency anemia.
Bleeding should be investigated:
Flexible sigmoidoscopy or anoscopy in low-risk
younger patients
Colonoscopy

33
 Pruritus

Irritation or itching of perianal skin

Some patients also complain of mild
incontinence or wetness.

34
 Pain
Thrombosis, which can occur in both internal
and external hemorrhoids. Thrombosis of
external hemorrhoids may be associated with
excruciating pain.

Easily visible, purple, elliptical mass

extending from the anal to the perianal skin.

Thrombosed internal hemorrhoids may also

cause pain, but to a lesser degree than
external hemorrhoids. An exception is when
internal hemorrhoids strangulate
35
 Therapy:
American Society of Colon and Rectal
Surgeons (ASCRS) Guidelines
Conservative (not generally effective in Grades III, IV)
Fiber
Meta-analysis of seven controlled trials found a significant
and consistent benefit from fiber supplementation in
improving bleeding (RR 0.50, 95% CI 0.28-0.68)
Also potentially useful:
Sitz baths
help to relieve irritation and pruritus. In warm water
two to three times per day.
Topicals
Steroids

Alonso-Coello P, et al. Cochrane Database Syst Rev 2005;(4):CD004649. 36

 Therapy

Minimally invasive
Mostly for Internal Grades I, II, III.
Band ligation
Coagulation
Sclerotherapy
Cryotherapy

37
 Therapy

Surgery
For refractory to above
Thrombosed external
Complications following a standard closed
hemorrhoidectomy include urinary retention,
urinary tract infection, fecal impaction,
delayed hemorrhage, and pain

38
 Therapy

In patients with thrombosed external

hemorrhoids
Either observation or excision. Excision
within 48 to 72 hours of the onset of
symptoms will result in the most rapid
relief of symptoms.

39
 Summary
Diverticular Disease
Diverticulosis is common and usually
asymptomatic.
Symptoms range from mild cramping and bowel
movement changes to life threatening infection or
hemorrhage
Diverticulitis is an infection of an diverticulum
Uncomplicated cases can be treatment with
outpatient oral antibiotics
Severe or complicated cases may require
hospitalization and invasive therapeutic
modalities
40
 Summary

Diverticular Bleeding
Is a common cause of massive lower GI
hemorrhage
Colonoscopy and angiography may be
diagnostic and therapeutic
Surgery is reserved for uncontrolled or
refractory cases with best outcomes when
the site of bleeding has been localized

41
 Summary
Hemorrhoids are common and can
cause bleeding, itching, or pain (with
thrombosis)
Mild cases can be treated with fiber
supplements and topical medications.
Minimally invasive (endoscopic)
techniques are available.
Surgery is reserved for severe cases or
thrombosis
42
Questions?

43