This document discusses diverticular disease and provides information on incidence, definitions, pathogenesis, epidemiology, clinical manifestations, evaluation, differential diagnosis, and management, including both non-operative and surgical treatment options. Diverticular disease is increasingly common, affecting over 50% of people over age 80. It is associated with low-fiber diets and risks like smoking. Clinical manifestations range from acute diverticulitis to chronic complications. Treatment depends on severity and includes antibiotics, percutaneous drainage, or surgery.

1. Diverticular Disease and
ABSITE REVIEW
Avery Walker, MD
Colon and Rectal Surgeon
@Averywalker21
The Colon Whisperer

2. Incidence
Increasing
• 5% at turn of the century
• 50% by 1975
• 5% by age 40 and 80% by age 80
1.5 – 2 million office visits
300,000-450,000 Admissions
1.5 million days of inpatient care
$1.8 BILLION of direct medical costs

3. • The most common location for a carcinoid tumor is ______.
• the appendix!
• If a mass is found in the appendix, what are the odds that it is a
carcinoid?
• ~80% of all appendiceal masses are carcinoids
• Small bowel carcinoids are much more aggressive than their
appendiceal and rectal counterparts
• If you encounter a carcinoid in the small bowel, what are the odds
that there is 2nd lesion?
• 30-40%
• If you suspect a carcinoid lesion on CT, what tests can help make
the diagnosis?
• Urinary 5-HIAA
• Chromogrannin A

4. Incidence
10-20% with Diverticula develop diverticulitis
10-20% of those with diverticulitis are admitted and treated
1% of those admitted will be treated operatively
Most patients admitted are treated non operatively

5. Definitions and Pathogenesis
Diverticulum – Thin wall outpouching of mucosa and
serosa but no muscularis – FALSE diverticulum
Diverticulosis – Prescense of diverticula
• Pathogensis: Altered Bowel motility = increased intraluminal pressures –
highest in the sigmoid colon
• Vasa recta penetrate the circular muscle layer
Diverticulitis
• Inflammation and focal necrosis
• Micro or macroscopic perforation of
a diverticulum

6. • Arise from the ____________.
• Interstitial cells of cajal (pacemaker cell of GI)
• 50% gastric, 25% small bowel, 25% colon/rectal
• 95% of GIST tumors have a mutation of the ________ gene.
• C-kit or CD117
• C-kit is a __________.
• Tyrosine Kinase receptor
• _________ is used as a specific chemotherapeutic agent against this
tyrosine kinase receptor.
• Gleevac or Imatinib
• What is a tyrosine kinase receptor that has been implicated in breast
cancer?
• Her2 neu
• What drug targets this receptor?
• Trastuzumab
• What is the most significant and dangerous side effect?
• “Trastuzumab trashes the heart:” CHF can occur
• Surgery for GIST can be aggressive:
• En bloc resection if necessary
• Need to take nodes?
• Only if palpable, GIST largely spreads hematogenously & locally

7. Epidemiology
Diet
• High red meat and low fiber diets
• Fiber may be protective - increases stool
water, decreases transit time
JAMA article 2008
- DIVERTICULITIS IS NOTASSOCIATED with
NUTS, CORN, and POPCORN CONSUMPTION

8. Epidemiology
• Higher in older patients
• Younger men – Fistulas
• Older men – Bleed
• Younger women – Perforate
• Older Women – Stricture
• Women tend to present 5 years later than men

9. Epidemiology - Risk Factors
Smoking – Increased
NSAIDS - Increased
Corticosteroids/Immunocompromised -
Increased
Opiates - Increased
Obesity - Increased
Alcohol - Increased

10. • Following resection of single <1 cm adenoma
• 5 years postpolypectomy
• If first colonoscopy is normal, resume average-risk recommendations
• Following resection of ≥1 cm or high-risk adenoma
• 3 years postpolypectomy
• Repeat colonoscopy in 3 years; if normal, return to average-risk
recommendations
• Following curative resection for colorectal cancer
• Within 1 year postoperatively
• Repeat in 3 years, then every 5 years
• Inflammatory bowel disease
• Within 8 years of diagnosis
• Survey for dysplasia every 1–2 years
•Personal history risk
•Initiate surveillance
•Interval

11. Clinical Manifestations
Acute
• Uncomplicated – No abscess (surrounding
inflammation)
• Complicated - abscess formation, perforation,
fistula, and bleeding
Fevers, leukocytosis, LLQ abdominal pain,
tachycardia, and hypotension
Dysuria, pneumaturia, and fecaluria

12. Hinchey Classification

13. Clinical Manifestations
Chronic
Persistent
Recurrent
Complex – Sequelae of chronic inflammation
Fistula
Stricture
Obstruction

14. Evaluation
History and Physical Exam
Labs
• CBC, Chemistry, UA, pregnancy test, LFTs, amylase, lipase
Imaging
• Acute abdominal series/upright CXR
• CT scan* - Most appropriate
• Abdominal ultrasound - alternative
• Contrast enema
• MRI - alternative

15. • Primary tumor (T)
• T1:
• <2cm
• T2:
• 2-5cm
• T3:
• >5cm
• T4:
• Tumor of any size invades adjacent organ(s), e.g., vagina, urethra,
bladder
• involvement of the sphincter muscle[s] alone is not classified as T4
• Regional lymph nodes (N)
• N1:
• perirectal lymph node(s)
• N2:
• unilateral internal iliac and/or inguinal lymph nodes
• N3:
• perirectal and inguinal lymph nodes
• and/or bilateral internal iliac
• and/or inguinal lymph nodes

16. • External Radiation
• Start day 1
• 5days/week x 5 weeks
• Systemic Chemotherapy (often is 5-fu)
• Start day 1 x 4days
• Repeat @ day 28
• Mitomycin C
• Give day 1

17. Differential Diagnosis
• Ischemic colitis
• Colorectal cancer
• Acute appendicitis
• Inflammatory bowel disease
• Infectious colitis
• Tubo-ovarian abscess, ovarian cyst, ovarian torsion,
ectopic pregnancy, cystitis, and nephrolithiasis

18. Management
• Outpatient non-operative
• Inpatient non-operative
• Operative

19. • Inflammatory
• Cell Migration & Proliferation
• Collagen Deposition
• Remodeling

20. Outpatient Non-operative
• Reliable, compliant, not sick, can tolerated PO,
available support.
• Oral antibiotics for 10 to 14 days.
• Gram-negative rods and anaerobes (particularly E.
coli and B. fragilis)
• Quinolone with metronidazole, amoxicillin-
clavulanate, or trimethoprim-sulfamethoxazole with
metronidazole

21. Inpatient Non-Operative
• Empiric broad-spectrum intravenous antibiotics.
• Percutaneous drainage of any abscess >3cm.
• Small abscesses can be treated with abx
• Ampicillin-sulbactam OR piperacillin-tazobactam OR
ticarcillin-clavulanate
• Third generation cephalosporin such as ceftriaxone
PLUS metronidazole
Usually better in 24-48 hours, No fevers, No abdominal
pain, Tolerate PO
Failure = continued pain, repeat CT after 4-7 days with
worse

22. • Macrophages

23. • Inflammatory

24. • 3-4 days

25. • Fibroblasts

26. • Neutrophil

27.  Platelets

28. Surgical Treatment
INDICATIONS ≠ NOT NUMBER
OF EPISODES
Routine elective resection based
on age is no longer recommended
Individualized based on risk factors

29. Surgical Indications Continued
Failure of abscess to respond to non-
operative treatment
• Medical Treatment
• Percutaneous drainage
Perforation/Sepsis
Obstruction

30. • Albumin: >3.5 g/dL
• Transferrin: >200 mg/dL
• Pre-albumin: >20 mg/dL

31. Types of Procedures
Historically: Staged Procedure – Colostomy --> Resection -->
Anastomosis
• Resection with Colostomy Formation --> Hartmann
procedure
• 35-45% of patients never have the colostomy reversed
• Resection with anastomosis
with or without a diverting
loop ileostomy
• Laparoscopic Lavage?

32. • Already have an elevated WBC
• Can’t scan them…
• US
• MRI
• Gravid uterus may displace the
appendix
• Acute appendicitis: 10% risk of fetal
loss
• Ruptured appendicitis: 30% fetal loss
• Be more aggressive in pregnant
patients with appendicitis
• Laparoscopy is tolerated well in
pregnancy
• Ruptured appendicitis isn’t
• Accept a higher negative
appendectomy rate in pregnant
women

33. Extent of Resection
Proximally – Entire sigmoid to NORMAL SUPPLE BOWEL
Distally – Proximal Rectum (Splaying of the teania )

34. • Bilirubin
• Bile Salts
• Primary: cholic & chenodeoxycholic acid
• Phospholipids
• Lecithin
• Cholesterol
• (Water)

35. • Cholesterol Stones
• Supersaturation of cholesterol
• Fat, female, forty, fertile
• Pigmented stones
• Calcium billirubinate
• Heme turnover
• Brown stones
• Chronic bacterial infection
• Form in the CBD

36. Follow up Colonoscopy?
6-8 weeks after an episode of Diverticulitis
Colitis
IBD
Cancer

37. • Less surgery for diverticulitis
• Most patients can be treated on an outpatient basis
• Age is no longer a factor when deciding to operate
• Current Guidelines state recurrence does not warrant
elective resection
• Nuts and Seeds are OK!!!
• The first episode is typically the worst
When do I operate
Persistent symptoms, aka smoldering diverticulitis,
failure of medical management while inpatient, fistula,
obstruction, stricture.
Conclusions