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Diverticular Disease of the Colon
CHAPTER 50
DIVERTICULAR DISEASE OF THE COLON Magdalene A. Brooke, MD, Gregory P. Victorino, MD, FACS
1. What is a colonic diverticulum? A protrusion of mucosa and submucosa through the muscular layers of the bowel wall. It has no muscular covering. Because these diverticula do not involve all layers of the bowel wall, they are really “false” diverticula. Diverticulum formation may be related either to weakness of the bowel wall at the sites of vessel perforation or to increased intraluminal pressure caused by low dietary fiber and constipation. 2. What is the difference between diverticulosis and diverticulitis? Diverticulosis is colonic diverticula without associated inflammation. Diverticulitis is inflammation and infection. Only 15% of patients with diverticulosis develop diverticulitis. 3. How does a diverticulum cause pain? Pain comes from inflammation or perforation of the diverticulum. If perforated, leakage may be scant and contained within pericolic fat or extensive, involving the mesentery, other organs, or the peritoneal cavity. Sigmoid diverticulitis typically causes pain in the left lower quadrant. 4. Where in the colon are diverticula usually located? In the United States, 95% of all diverticula occur in the left colon, primarily in the sigmoid colon. Diverticula, however, may occur anywhere in the colon. In Asia, right colonic diverticula are more common. The diverticula tend to occur on the mesenteric side of the antimesenteric tinea, where small perforating blood vessels create a weakness in the circular muscle of the colon. 5. At what age is diverticulitis most common? The sixth or seventh decade of life. Younger patients are more likely than older patients to have right colonic diverticulitis. 6. What strategy may decrease diverticulitis in patients with diverticula? A high-fiber diet. Large bulk in the colon decreases segmentation and intraluminal pressure. 7. What is the best imaging test for diagnosing acute diverticulitis? Computed tomography (CT) scan, which can also diagnose local complications of diverticulitis. 8. What are the possible complications in complicated diverticulitis? • Perforation • Inflammatory phlegmon or abscess in the bowel mesentery • Peritonitis • Intraabdominal abscess • Internal fistula • Bowel obstruction 9. Can diverticular disease cause bleeding? Yes. Diverticulosis (not -itis) is a common cause of lower gastrointestinal bleeding. Bleeding from diverticulitis is uncommon. 10. How can the site of diverticular bleeding be localized? Colonoscopy is considered first line to localize lower gastrointestinal (GI) bleeding as it also offers the opportunity to intervene using thermal coagulation, epinephrine injection, or endoscopic clipping. Patients must be adequately resuscitated prior to the procedure. If bleeding is not seen at the time of colonoscopy or a colonoscopy is not technically possible, other localization methods include CT angiography and tagged red blood cell scan.
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Diverticular Disease of the Colon 225 11. When should an operation be performed for a bleeding colonic diverticulum? Replacement of 5–6 units of blood (two-thirds of a patient’s blood volume) within 24 hours and rebleeding during hospitalization are standard indications for resection of the segment of colon containing a bleeding diverticulum. 12. If bleeding is life threatening but cannot be localized within the colon, what treatment is required? Subtotal colectomy with temporary ileostomy and closure of the distal sigmoid colon at the peritoneal reflection (Hartmann procedure) or total abdominal colectomy with ileorectal anastomosis is required. This operation carries a high risk of mortality. 13. What is the clinical evidence of a vesicocolic or ureterocolic fistula after diverticular perforation? Pneumaturia, fecaluria, and chronic urinary tract infections (polymicrobial). 14. What procedure is required to repair a vesicocolic fistula? A staged procedure was the standard until recently. Now most patients can be treated with a single procedure that includes sigmoid resection, colonic anastomosis, and primary repair of bladder defect with absorbable suture. A Foley catheter is usually left in place for 10 days after surgery. Some viable tissue should be placed between the colonic and bladder repairs to prevent a recurrent fistula. 15. How is complicated diverticulitis classified clinically? Diverticulitis is classified by the Hinchey classifications, originally proposed in 1978: • Class I – Localized, paracolonic abscess • Class II – Pelvic abscess • Class III – Purulent peritonitis • Class IV – Fecal peritonitis 16. When should diverticulitis be managed operatively in the acute setting? The current guidelines on management of diverticulitis recommend resection of the affected segment of colon in the setting of purulent or fecal peritonitis (Hinchey III and IV), or in the case of failure to improve with nonoperative management. There is controversy, however, regarding the best operative choice to manage the resection.
CONTROVERSIES 17. What operation should be performed for severe diverticulitis? Options for acute operative management of complicated diverticulitis include the following: a. Open resection with end colostomy (Hartmann procedure) b. Open resection with primary anastomosis, plus/minus protective ileostomy Classically, it has been the standard to perform option a, resection with end colostomy, because of the concern for creation of an anastomosis in an inflamed, infected setting. However, there is emerging literature supporting primary anastomosis, possibly with diverting ileostomy to protect the anastomosis. The current literature is split on the safety of this technique in the urgent or emergent setting. Guidelines recommend relying on surgeon’s preference and clinical judgment to decide which is appropriate in a given clinical scenario. Option a is the safer choice in a grossly contaminated or inflamed field. 18. Should patients with recurrent diverticulitis receive elective, prophylactic colectomy? For many years the thought was that prophylactic colectomies should be performed in the setting of recurrent diverticulitis in order to prevent both future episodes and future complications requiring colostomy. Recently, this strategy has come into question. Studies overall do not find that use of elective colectomy reduces the risk of episodes of complicated diverticulitis in the future. Consensus guidelines are moving away from recommending elective resection based on age of the patient or number of episodes of uncomplicated diverticulitis, but more data is needed to assess the value of elective resection. There is still evidence to support considering elective colectomy after episodes of complicated diverticulitis requiring abscess drainage or other invasive therapy. The use of laparoscopic colon resection in appropriately experienced hands is supported in the literature, and recommended in current guidelines.
226 ABDOMINAL SURGERY K EY POIN T S: LOC AL IZ AT I O N O F L O W ER G I B L E ED I N G 1. In cases of hematochezia, it is important to rule out upper GI source of bleeding with placement of a nasogastric tube. Return of bile without blood is proof of lower GI source. Otherwise, EGD should be performed. 2. Common lower GI causes: Diverticulosis, cancer, angiodysplasia. 3. Tagged red blood cell nuclear scans are useful for slower GI bleeding (detects bleeding at 0.2–0.5 mL/min).
Bibliography 1. Buchs NC, Mortensen NJ. Natural history of uncomplicated sigmoid diverticulitis. World J Gastrointest Surg. 2015;7(11):313–318. 2. Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg. 207;245(1):94–103. 3. Simpson J, Scholefield JH. Pathogenesis of colonic diverticula. Br J Surg. 2002;89(5):546–554. 4. Frattini J, Longo WE. Diagnosis and treatment of chronic and recurrent diverticulitis. J Clin Gastroenterol. 2006;40(suppl 3):S145–S149. 5. Feingold D, Steele S, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284–294. 6. Hinchey EJ, Schaal PG. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85–109. 7. Moghadamyeghaneh Z, Carmichael JC, Smith BR, et al. A comparison of outcomes of emergent, urgent, and elective surgical treatment of diverticulitis. Am J Surg. 2015;210(5):838–845. 8. Oberkolfer CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256(5):819–827. 9. Pasha SF, Shergill A, Acosta RD, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014;79(6):875–885. 10. Richter S, Lindemann W. One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV). World J Surg. 2006;30(6):1027–1032. 11. Schulz JK, Yaqub S, Wallon C, et al. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: The SCANDIV randomized clinical trial. JAMA. 2015;314(13):1364–1375. 12. Simianu VV, Strate LL, Billingham RP, et al. The impact of elective colon resection on rates of emergency surgery for diverticulitis. Ann Surg. 2016;263(1):123–129. 13. Vennix S, Morton DG, Hahnloser D, et al. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis. 2014;16(11):866–878.
DIVERTICULAR DISEASE OF THE COLON Magdalene A. Brooke, MD, Gregory P. Victorino, MD, FACS
1. What is a colonic diverticulum? A protrusion of mucosa and submucosa through the muscular layers of the bowel wall. It has no muscular covering. Because these diverticula do not involve all layers of the bowel wall, they are really “false” diverticula. Diverticulum formation may be related either to weakness of the bowel wall at the sites of vessel perforation or to increased intraluminal pressure caused by low dietary fiber and constipation. 2. What is the difference between diverticulosis and diverticulitis? Diverticulosis is colonic diverticula without associated inflammation. Diverticulitis is inflammation and infection. Only 15% of patients with diverticulosis develop diverticulitis. 3. How does a diverticulum cause pain? Pain comes from inflammation or perforation of the diverticulum. If perforated, leakage may be scant and contained within pericolic fat or extensive, involving the mesentery, other organs, or the peritoneal cavity. Sigmoid diverticulitis typically causes pain in the left lower quadrant. 4. Where in the colon are diverticula usually located? In the United States, 95% of all diverticula occur in the left colon, primarily in the sigmoid colon. Diverticula, however, may occur anywhere in the colon. In Asia, right colonic diverticula are more common. The diverticula tend to occur on the mesenteric side of the antimesenteric tinea, where small perforating blood vessels create a weakness in the circular muscle of the colon. 5. At what age is diverticulitis most common? The sixth or seventh decade of life. Younger patients are more likely than older patients to have right colonic diverticulitis. 6. What strategy may decrease diverticulitis in patients with diverticula? A high-fiber diet. Large bulk in the colon decreases segmentation and intraluminal pressure. 7. What is the best imaging test for diagnosing acute diverticulitis? Computed tomography (CT) scan, which can also diagnose local complications of diverticulitis. 8. What are the possible complications in complicated diverticulitis? • Perforation • Inflammatory phlegmon or abscess in the bowel mesentery • Peritonitis • Intraabdominal abscess • Internal fistula • Bowel obstruction 9. Can diverticular disease cause bleeding? Yes. Diverticulosis (not -itis) is a common cause of lower gastrointestinal bleeding. Bleeding from diverticulitis is uncommon. 10. How can the site of diverticular bleeding be localized? Colonoscopy is considered first line to localize lower gastrointestinal (GI) bleeding as it also offers the opportunity to intervene using thermal coagulation, epinephrine injection, or endoscopic clipping. Patients must be adequately resuscitated prior to the procedure. If bleeding is not seen at the time of colonoscopy or a colonoscopy is not technically possible, other localization methods include CT angiography and tagged red blood cell scan.
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Diverticular Disease of the Colon 225 11. When should an operation be performed for a bleeding colonic diverticulum? Replacement of 5–6 units of blood (two-thirds of a patient’s blood volume) within 24 hours and rebleeding during hospitalization are standard indications for resection of the segment of colon containing a bleeding diverticulum. 12. If bleeding is life threatening but cannot be localized within the colon, what treatment is required? Subtotal colectomy with temporary ileostomy and closure of the distal sigmoid colon at the peritoneal reflection (Hartmann procedure) or total abdominal colectomy with ileorectal anastomosis is required. This operation carries a high risk of mortality. 13. What is the clinical evidence of a vesicocolic or ureterocolic fistula after diverticular perforation? Pneumaturia, fecaluria, and chronic urinary tract infections (polymicrobial). 14. What procedure is required to repair a vesicocolic fistula? A staged procedure was the standard until recently. Now most patients can be treated with a single procedure that includes sigmoid resection, colonic anastomosis, and primary repair of bladder defect with absorbable suture. A Foley catheter is usually left in place for 10 days after surgery. Some viable tissue should be placed between the colonic and bladder repairs to prevent a recurrent fistula. 15. How is complicated diverticulitis classified clinically? Diverticulitis is classified by the Hinchey classifications, originally proposed in 1978: • Class I – Localized, paracolonic abscess • Class II – Pelvic abscess • Class III – Purulent peritonitis • Class IV – Fecal peritonitis 16. When should diverticulitis be managed operatively in the acute setting? The current guidelines on management of diverticulitis recommend resection of the affected segment of colon in the setting of purulent or fecal peritonitis (Hinchey III and IV), or in the case of failure to improve with nonoperative management. There is controversy, however, regarding the best operative choice to manage the resection.
CONTROVERSIES 17. What operation should be performed for severe diverticulitis? Options for acute operative management of complicated diverticulitis include the following: a. Open resection with end colostomy (Hartmann procedure) b. Open resection with primary anastomosis, plus/minus protective ileostomy Classically, it has been the standard to perform option a, resection with end colostomy, because of the concern for creation of an anastomosis in an inflamed, infected setting. However, there is emerging literature supporting primary anastomosis, possibly with diverting ileostomy to protect the anastomosis. The current literature is split on the safety of this technique in the urgent or emergent setting. Guidelines recommend relying on surgeon’s preference and clinical judgment to decide which is appropriate in a given clinical scenario. Option a is the safer choice in a grossly contaminated or inflamed field. 18. Should patients with recurrent diverticulitis receive elective, prophylactic colectomy? For many years the thought was that prophylactic colectomies should be performed in the setting of recurrent diverticulitis in order to prevent both future episodes and future complications requiring colostomy. Recently, this strategy has come into question. Studies overall do not find that use of elective colectomy reduces the risk of episodes of complicated diverticulitis in the future. Consensus guidelines are moving away from recommending elective resection based on age of the patient or number of episodes of uncomplicated diverticulitis, but more data is needed to assess the value of elective resection. There is still evidence to support considering elective colectomy after episodes of complicated diverticulitis requiring abscess drainage or other invasive therapy. The use of laparoscopic colon resection in appropriately experienced hands is supported in the literature, and recommended in current guidelines.
226 ABDOMINAL SURGERY K EY POIN T S: LOC AL IZ AT I O N O F L O W ER G I B L E ED I N G 1. In cases of hematochezia, it is important to rule out upper GI source of bleeding with placement of a nasogastric tube. Return of bile without blood is proof of lower GI source. Otherwise, EGD should be performed. 2. Common lower GI causes: Diverticulosis, cancer, angiodysplasia. 3. Tagged red blood cell nuclear scans are useful for slower GI bleeding (detects bleeding at 0.2–0.5 mL/min).
Bibliography 1. Buchs NC, Mortensen NJ. Natural history of uncomplicated sigmoid diverticulitis. World J Gastrointest Surg. 2015;7(11):313–318. 2. Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg. 207;245(1):94–103. 3. Simpson J, Scholefield JH. Pathogenesis of colonic diverticula. Br J Surg. 2002;89(5):546–554. 4. Frattini J, Longo WE. Diagnosis and treatment of chronic and recurrent diverticulitis. J Clin Gastroenterol. 2006;40(suppl 3):S145–S149. 5. Feingold D, Steele S, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284–294. 6. Hinchey EJ, Schaal PG. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85–109. 7. Moghadamyeghaneh Z, Carmichael JC, Smith BR, et al. A comparison of outcomes of emergent, urgent, and elective surgical treatment of diverticulitis. Am J Surg. 2015;210(5):838–845. 8. Oberkolfer CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256(5):819–827. 9. Pasha SF, Shergill A, Acosta RD, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014;79(6):875–885. 10. Richter S, Lindemann W. One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV). World J Surg. 2006;30(6):1027–1032. 11. Schulz JK, Yaqub S, Wallon C, et al. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: The SCANDIV randomized clinical trial. JAMA. 2015;314(13):1364–1375. 12. Simianu VV, Strate LL, Billingham RP, et al. The impact of elective colon resection on rates of emergency surgery for diverticulitis. Ann Surg. 2016;263(1):123–129. 13. Vennix S, Morton DG, Hahnloser D, et al. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis. 2014;16(11):866–878.