Ulcerative colitis
- Screening – yearly colonoscopy starting after 10 years of UC
D
IVERTICULAR DISEASEPATHOLOGY – acquired herniation of colonic mucosa through muscular wall, with a covering of colonic serosa
TERMS
- Diverticulosis coli – presence of acquired pseudodiverticula - Diverticular disease – symptomatic diverticulosis coli - Diverticulitis – inflammation of diverticula
EPIDEMIOLOGY
- Increases with age; up to 25% in >70YO
- Majority are asymptomatic; 10-30% are symptomatic - Risk factors – dietary fibre & genetics
- Site – majority are in the sigmoid colon (right sided are thought to be genetic; in Asians; left sided are more in Caucasians; not in rectum as taeni coli has fused)
PATHOGENESIS
1. Increased intraluminal pressure - Associated with lack of dietary fibre 2. Degenerative changes in colonic wall
- Usually at point of entry of terminal arterial branches where serosa is weakest - Associated with weakening of collagen structure with age
PRESENTATIONS 1. Acute diverticulitis
- Symptoms: LLQ pain, N/V, Constipation / diarrhoea - Signs: Low grade fever, Tender palpable mass - Investigation: WBC
2. Chronic diverticulitis - Recurrent LIF pain - Irregular bowel habit - Passage of mucus PR 3. Complicated diverticulitis
a. Perforation
b. Paracolic abscess / inflammatory mass – 2o to localized perforation c. Bowel obstruction – 2o to structure or adherence to a diverticular mass d. LGIT haemorrhage – ulcerated vessel @ neck of diverticulum; torrential e. Fistula formation (commonest: colovesical fistula) – 2o to pericolic abscess
discharging, operation or drainage of pericolic abscess. May present with urinary symptoms. Others – cutaneous, uterine, enteric, colo-vaginal
STAGING
- Hinchey classification of acute diverticulitis – need for surgery is reflected by degree of infective complications
Stage 1 Pericolonic / Mesenteric abscess
- ABx, NBM, IV fluids
- Consider 1 stage surgery after acute episode – resection of affected bowel segment with primary anastomosis
Stage 2 Pelvic / retroperitoneal abscess
- Percutaneous drainage - Elective 1 stage surgery
Stage 3 Purulent peritonitis - 2 stage operation – Hartmann‘s procedure (partial colectomy + diverting end colostomy & rectal stump formation) + secondary re-anastomosis 3 months later
Stage 4 Faecal peritonitis
Note: current controversy of management for stage 3: haartman‟s vs segmental resection with primary anastomosis with or without defunctioning ileostomy
Presentation Clinical features Investigations Differentials Management Acute
Diverticulitis
- LIF pain – colicky, progressing to constant, relieved by defecation - LIF tenderness - Erect CXR to rule out perforation
- AXR – ileus, air-fluid level w/in an abscess - Barium enema
- CT scan w triple contrast
Contrast: IV for vascular lesions, oral for small bowels, enema for large bowels
Features – diverticula elsewhere, confirm colitis (mesenteric fat infiltration, concentric bowel thickening) but only suggest diverticulitis, pelvic abscess, free gas, extravasated contrast
Cannot tell if inflm is due to diverticula - Laparoscopy – if diagnosis is in doubt
- Avoid colonoscopy as risk of perforation is high
- See Ddx to RIF/LIF pain - GI: appendicitis, colitis, GE,
IBS, IBD, mesenteric ischaemia/ adenitis, Ca colorectal
- Broad-spectrum antibiotics – augmentin or metronidazole or ciprofloxacin
- Antispasmodics
After acute phase has settled - Ba enema &/or Colonoscopy –
confirm dx & exclude CA colon Role of surgery: see behind
Chronic
- Irregular bowel habits – constipation
& bouts of diarrhoea - Passage of mucus PR
- Ruled out cancer, IBD, ureteric colic, Msk pain etc.
- Rigid sigmoidoscopy – oedematous mucosa &
rigidity of rectosigmoid junction
- Flexible sigmoidoscopy – diverticular orifices - Barium enema – ‗saw-tooth‘ appearance,
diverticula, strictures
- Colonoscopy – exclude differentials (i.e. Ca colon)
- CA colon – may coexist.
Hard to differentiate – therefore, ALWAYS exclude CA colon e.g.
histology after bowel resection
- Ischaemic colitis - Radiation colitis - Colonic endometriosis
Conservative – see above Surgical
Indications:
- Severe / recurrent attacks - Possible CA colon
- Segmental resection of affected colon + anastomosis
Generalised peritonitis / perforation
- Acute onset abdominal pain – severe
& continuous
- Abdominal guarding & rigidity - Vomiting AA/ hepatoma, torsion of testis/ ovary, pyonephrosis
Mgmt as for acute abdomen - Resuscitate
- Surgical
Peritoneal toilet
Resection of affected segment
End sigmoid colostomy (Hartmann‘s procedure) Pericolic
abscess
- May follow acute diverticulitis - LIF tenderness & guarding
- LIF mass – may be detected on DRE - Swinging fever
- FBC – ↑ TW
- CT – differentiate between inflammatory phlegmon
& pericolic abscess
- CT/US guided percutaneous aspiration
- Surgery – evacuation of pus ± resection of affected segment
Persistent inflammatory mass
- LIF pain, tenderness & palpable mass - Fever
- Malaise
Small bowel I/O
- Usually temporary, due to attachment of enteric loop against area of acute diverticulitis - Surgery if does not resolve
Presentation Clinical features Investigations Differentials Management Large bowel
I/O
- PHx of recurrent acute diverticulitis or irregular bowel habit
- Colicky abdominal pain, constipation
& abdo distension
- AXR – dilated bowels proximal to stenosis - Water soluble contrast enema
- CA colon - NBM, Drip & suck
- Surgery – Resection ± primary anastomosis
Hemorrhage - Usually in the elderly who have higher density of sigmoid diverticula - Massive bleed (altered blood ± clots;
not melena) usually right-sided - Colicky pain as blood is irritative &
causes spasm
- Invx as for LGIT bleed – resus, invesigations + colonoscopy & angiography (both diagnostic AND therapeutic value)
- ± on-table enteroscopy if required
- ± tagged RBC scan (not as sensitive compared to angiogram)
- Anorectal bleed - Angiodysplasia - Ischaemic colitis - Colorectal CA - Colitis (inflm or infx) - UBGIT
- Coagulopathy
- Resuscitate & correct coagulopathy - Colonoscopic management:
adrenaline injection, endoclips on bleeding vessel, heat coagulation - Radiologic embolisation of site of
bleeding with temp foam material via angiography
- Surgery – segmental resection;
total colectomy if unable to localise bleed
Vesicocolic fistula
- PHx of chronic diverticulitis & UTI - Hx of dysuria, freq, haematuria,
pneumaturia, faecaluria
- UFEME & urine c/s: confirm UTI and organisms - Cystoscopy – cystitis
- Sigmoidoscopy – usually normal - KUB – air in bladder
- Barium enema – diseased diverticular bowel segment
- Other causes of fistula – CA colon, CA bladder, Crohn‘s disease, post-irradiation necrosis
- Surgery – Resection of affected colon + anastomosis + closure of bladder fistula opening
Outcomes: well or derteriorate requiring surgery, recurrent episodes, stricture & subacute IO (offer surgery) Indications for emergency operation 1. Sepsis from abscess or faecal peritonitis
2. Perforation
3. Diverticulitis not responding to conservative management
4. Obstruction with pending perforation – need to rule out cancer at the same time
5. Emergency bleed (controversial clamping both side & look for active bleed into segment segmental resection) a. Haemodynamically unstable with failure of embolization
b. Need > 4 units of PCT c. Previous bleed Indications for elective operation 1. Stricture
2. Fistula
3. Recurrent attacks – occurs in 30% of patients after 1st episode. a/w higher mortality & complication rates 4. Young patientss <40YO – high recurrence rates
5. Immunocompromised patients (e.g. renal transplant) – may not show S/S of acute attack or complications Advice to patients:
- 70% of patients will not have recurrence after first attack - Advise high fibre diet & to drink lots of fluid