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H.K. Oh M.D.
Department of General Surgery
 Overview
r A J
  is an abnormal sac or pouch
protruding from the wall of a hollow organ.
ƥ Diverticula ; pouches
ƥ Diverticulosis ; condition of having diverticula
r |
 

is a common condition of Western
society and seems to be an unfortunate product of
the Industrial Revolution.
ƥ Decreased consumption of unprocessed cereals along
with the increased consumption of sugar and meat
r The formation of diverticula is also related to aging
ƥ Rare in individuals younger than the age of 30 years, but
at least two thirds of Americans will have developed
colonic diverticula by the age of 80.
 ^athogenesis
r Diverticula are actually herniations of
mucosa through the colon at sites of
penetration of the muscular wall by
arterioles
ƥ On the mesenteric side of the
antimesenteric teniae
r Sigmoid colon
ƥ The most common site (50%)
ƥ The smallest luminal diameter.
ƥ Low fiber diet
-> decreased colonic luminal content
-> high intraluminal pressures to propel the
feces forward
-> herniations of mucosa through the
anastomically weak points in the colonic wall
 Diverticular bleeding
r The most common cause of hematochezia in
patients over the age of 60
ƥ 20% of patients with diverticulosis will have GI bleeding.
r Risk factor ; HT, Artherosclerosis, NSAID
r Usually self limited, but rebleeding risk (25%)
r Localization ; Colonoscopy, Angiography
r Surgery
ƥ Unstable hemodynamics, 6-unit bleed within 24 hr
ƥ Without localization ; Total colectomy
 Diverticulitis
r Definition
ƥ Inflammation of a diverticulum, is related to the
retention of particulate material within the
diverticular sac and the formation of a fecalith
ƥ Actually an extraluminal pericolic infection caused
by the extravasation of feces through the
perforated diverticulum
r ^resentation
ƥ LLQ pain : may radiate to the suprapubic, groin,
back
ƥ Bowel habit change, Anorexia, Fever, Chill,
Urinary urgency
 Diverticulitis
r ^hysical Findings
ƥ Dependent on the site of perforation, the amount
of contamination, and the presence or absence of
secondary infection of adjacent organs
ƥ Tenderness, Muscle guarding
ƥ Tender mass : phlegmon or abscess
ƥ Abdominal distension : ileus or obstruction
ƥ Tender fluctuant pelvic mass on rectal or vaginal
exam
 Diverticulitis
r Diagnostic Tests
ƥ CT
The preferred test to confirm the suspected diagnosis
Location of infection, extent of inflammatory process,
presence and location of an abscess, secondary
complications
sigmoid diverticula, thickened colonic wall >4 mm, inflammation
within the pericolic fat † the collection of contrast material or fluid
ƥ MRI, US
ƥ Water soluble contrast enema
Distinguish acute diverticulitis from perforated cancer
Risk of increasing the colonic pressure, extravasation
of feces through the perforated diverticulitis
 Uncomplicated Diverticulitis
r Disease not associated with free intraperitoneal
perforation, fistula formation, or obstruction
r Nonoperative treatment
ƥ Bowel rest + Antibiotics ; 75% response
ƥ ë
 
 
 or 




and 

J
 ; aerobic gram-negative rods and
anaerobic bacteria
ƥ The addition of 


 to this regimen for
nonresponders ; enterococci
ƥ Single-agent therapy ; a third-generation penicillin such
as 
 


ƥ The usual course of antibiotics is 7 to 10 days
 Uncomplicated Diverticulitis
r Investigative studies
ƥ After the symptoms have subsided for at least 3 weeks
ƥ To establish the presence of diverticula and to exclude
cancer, which can mimic diverticulitis
ƥ Colonoscopy > Barium enema
r Recurrent disease
ƥ Second attack (<25%) -> Third attack (>50%)
ƥ Elective resection
After infection control ; usually 4 to 6 weeks after the episode
Laparoscopic resection ; growing trend
Immunocompromised patient : after single attack
 Complicated Diverticulitis
r Hinchey classification
ƥ Stage I: ^ericolic or
mesenteric abscess

ƥ Stage II: Walled-off

pelvic abscess

ƥ Stage III: Generalized

purulent peritonitis

ƥ Stage IV: Generalized

fecal peritonitis
 Complicated Diverticulitis
Abscess
r Usually confined to the
pelvis
r Significant pain, fever, and
leukocytosis
r More than 2cm ; should be
drained
ƥ ^ercutaneous or transanal >
laparotomy
r Elective surgery ; after
6weeks following drainage
ƥ Complete removal of the entire
abnormally thickened bowel
 Complicated Diverticulitis
Fistula
r Skin, bladder, vagina, or small bowel
r Sigmoid-vesical fistula
ƥ ^neumaturia, fecaluria,
and recurrent UTI (Urosepsis)
ƥ CT ; may demonstrate air
in the bladder
ƥ Barium enema, IV^, Cystoscopy
r Treatment
ƥ Initial treatment ; infection control and reduce the
associated inflammation
ƥ Rarely a cause for emergency surgery
ƥ Diagnostic steps such as coloscopy should be taken to
confirm the cause of the fistula before a definitive
operation is undertaken.
 Generalized ^eritonitis
r Mechanism
ƥ ^erforation without sealing by the bodyƞs normal
defenses -> contaminated with feces
ƥ Abscess burst into the unprotected peritoneal cavity
-> contaminated with enteric bacteria
r Immediate operative intervention
ƥ Excise the segment of colon containing perforation and
construct a colostomy using noninflammed colon
ƥ ^eritoneal cavity irrigation, iv antibiotics
r Colostomy repair
ƥ Usually after a period of at least 10 weeks
 Diverticulosis in Korea
r Characteristics
ƥ Low incidence, but increasing
ƥ Rt colon (over 60%) > Lt colon
ƥ Young Age, Man, Congenital, Solitary, True type,
Uncomplicated type
r Differential Diagnosis from Acute Appendicitis
ƥ RLQ pain ; first symptom site, long duration
ƥ Nausea, vomiting ; absent or low
ƥ ^revious appendectomy
ƥ Known diverticulosis (Barium enema, Colonoscopy)
ƥ Fecalith
ƥ Age ; 30~40 year old (later than appendicitis)
ƥ History of lower GI bleeding
 References
r Sabiston Textbook of Surgery 17ed
r Harrisonƞs ^rinciples of Internal Medicine 16th
r Whetsone D, Hazey J, ^ofahl WE 2nd, Roth JS. Current
management of diverticulitis. Curr Surg. 2004 Jul-
Aug;61(4):361-5
r Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of
elective colectomy in diverticulitis: a decision analysis. J Am
Coll Surg. 2004 Dec;199(6):904-12.
r Natarajan S, Ewings EL, Vega RJ. Laparoscopic sigmoid
colectomy after acute diverticulitis: when to operate?
Surgery. 2004 Oct;136(4):725-30.
r ^ark JK et al. Clinical analysis of right colon diverticulitis. J
Korean Surg Soc 2003 Jan;64:44-48
r Chang JH et al. Surgical treatment of the colonic
diverticulosis. J Korean Surg Soc 2002 May;62:415-420
Thank you for your attentions.