Combined 03 clinical training--pathology benign_diverticular disease

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BENIGN PATHOLOGYBENIGN PATHOLOGYDiverticular DiseaseDiverticular Disease

Common Colonic Pathology

Diverticular Disease – Introduction

• Colonic diverticula are out-pouchings of the colonic wall.

• Essentially, the mucosa herniates through the muscular wall.

• Occur where mesenteric vessels penetrate the bowel wall.

Diverticular Disease – Prevalence

• The overall prevalence of diverticular disease is 27 percent and increases with patient age.

• The prevalence of diverticula may be as high as 60 percent in patients older than 80 years, with no clear gender difference.

• Diverticular disease is a disease of Western man and is primarily left-sided.

• Right-sided diverticular disease is almost exclusively an Asian condition and is more common in Asians than left-sided.

Diverticular Disease – Diagnosis

• In many cases, the clinical manifestations of the disease will allow diagnosis with reasonable confidence.

• The WBC has been found to be normal in 2/3 of patients with acute complications of diverticular disease.

• A routine abdominal series rarely offers any specific diagnostic information.

• The use of ultrasonography, CT scan of the abdomen, or a water-soluble contrast enema may be useful when the diagnosis is not clear.

Diverticular Disease – Diagnosis

• Double contrast (water-soluble) enema allows diagnosis, assessment of extent, and complications of diverticular disease.

Diverticular Disease – Diagnosis

• A common radiologic finding is some degree of colonic spasm, creating a zigzag appearance.

Diverticular Disease – Diagnosis

• In many cases, the clinical manifestations of the disease will allow diagnosis with reasonable confidence.

• The WBC has been found to be normal in 2/3 of patients with acute complications of diverticular disease.

• A routine abdominal series rarely offers any specific diagnostic information.

• The use of ultrasonography, CT scan of the abdomen, or a water-soluble contrast enema may be useful when the diagnosis is not clear.

• Colonoscopy may reveal the presence of diverticula and may be useful in differentiating stenosis caused by chronic diverticular inflammation from that caused by carcinoma.

Diverticular Disease – Diagnosis

• Colonoscopy may be helpful, but often overlooks minor degrees of diverticular disease.

Diverticular Disease – Diagnosis

• CT scan +/- intravenous and rectal contrast -- useful for imaging abscesses, fistulae, as well as other complications.

• Extended areas of stenosis (or narrowing) may be seen on x-ray and must be differentiated from carcinoma.

• Colonoscopy has proven to be useful in this differentiation, but the area of narrowing must be fully traversed.

• Plain X-rays with positive diagnostic features (e.g. free air, gas in bladder) may demonstrate complications.

• Normal X-rays cannot exclude complications of diverticular disease.

Diverticular Disease – Diverticulosis

• Diverticulosis is an anatomic diagnosis that describes the presence of one or more diverticula.

• Uncomplicated, asymptomatic diverticular disease typically is diagnosed incidentally and does not require further work-up.

Diverticulosis – Symptoms

• 80 to 85 percent of patients with diverticular disease will remain asymptomatic, as only a small percentage of patients will develop symptomatic diverticular disease.

• Symptomatic diverticular disease is characterized by nonspecific attacks of abdominal pain without evidence of an inflammatory process.

• Some patients will experience ill-defined left-sided abdominal pain.

• Anorexia, nausea, and flatulence may occur.

• Rectal bleeding is uncommon in uncomplicated disease.

Diverticulosis – Symptoms

• Many patients with symptomatic diverticular disease will experience moderate abdominal pain but without overt inflammation.

• This pain typically is colicky in nature, but can be steady, and is often relieved by passing flatus or a bowel movement.

• Bloating and changes in bowel habits also can occur, and constipation is more common than diarrhea.

• Fullness or tenderness in the left lower quadrant, or occasionally a tender palpable loop of sigmoid colon, is often appreciated on physical examination.

Diverticular Disease – Diverticulitis

• Diverticulitis indicates that inflammation of a diverticulum has occurred.

• Approximately 10-25 percent of all patients with diverticula develop diverticulitis, and a small number of those will develop further complications of diverticulitis such as abscess formation, perforation, fistulas, obstruction, or hemorrhage.

Diverticular Disease – Diverticulitis

• Diverticulitis is not limited to the sigmoid colon and may also be seen in the cecum, mimicking acute appendicitis, infectious colitis, or inflammatory bowel disease.

• Diverticulitis is less frequently seen in the transverse colon and rarely in the rectum.

• Diverticulitis is believed to develop as the result of a micro- or macro-perforation of a diverticulum, which may be caused by erosion of the luminal wall due to increased intraluminal pressure or thickened fecal material in the neck of the diverticulum.

• After a micro-perforation, infection is generally contained by pericolonic fat, mesentery, or adjacent organs, and a localized phlegmon occurs.

Diverticulitis – Symptoms

• Diverticulitis is characterized by acute, constant abdominal pain most often occurring in the left lower quadrant.

• The pain is usually quite severe, likely due to the presence of the associated inflammation.

• Fever and leukocytosis are generally present, often associated with nausea, vomiting, and constipation or diarrhea.

• Right-sided diverticulitis can easily be confused with many other problems, including appendicitis, and is usually able to be treated without surgery.

Diverticulitis – Complications

• Complications of diverticulitis include:

– Perforation

– Fistula

– Hemorrhage

– Bowel obstruction.

• These complications all require surgical consultation.

Diverticulitis – Perforation

• With macro-perforation, the resultant infection is less restricted, and a pericolonic abscess or peritonitis can occur.

Diverticulitis – Perforation

• Perforation—

– Abscesses occur when the pericolic tissues fail to control the spread of the inflammatory process caused by perforation.

– Abscess formation should be suspected when fever, leukocytosis, and/or pain persist despite an adequate trial of appropriate antibiotics, IV fluids, and diet restriction.

– Perforation can result in findings that may be classified into four clinical categories.

Diverticulitis – Perforation

• Perforation—

– Stage I: Localized pericolic or mesenteric abscess

– Stage II: Walled-off pelvic abscess

– Stage III: Generalized purulent peritonitis

– Stage IV: Generalized fecal peritonitis

Diverticulitis – Perforation

• Stage I: Localized pericolic or mesenteric abscess—

– Most common complication of sigmoid diverticulitis.

– May be pericolic or involve the mesentery.

– Varying degrees of pain and tenderness occur.

– Barium should not be used—use water-soluble contrast for x-ray.

– Initially treat with antibiotics and bowel rest.

Diverticulitis – Perforation

• Stage II: Walled-off pelvic abscess—

– If no improvement in previous patient after 3-5 days of appropriate treatment, consider walled-off pelvic abscess.

– Rectal or vaginal exam may reveal tender, bulging mass.

– Hypovolemia or sepsis may occur.

– Confirm diagnosis with US or CT scan.

– Treat with IV’s, antibiotics, and CT- or US-guided percutaneous drainage.

Diverticulitis – Perforation

• Stage III: Generalized purulent peritonitis—

– May arise from persistent leakage from perforated diverticulitis or sudden rupture of walled-off pericolic or pelvic abscess.

– Give appropriate medical support with prompt surgical treatment.

• Resect the perforated segment.

• Don’t do more than necessary—definitive procedure later.

• Don’t do extensive peritoneal dissection, mobilize splenic flexure, or enter presacral space—might further sepsis.

• Don’t make mucous fistula—Hartman procedure works!

• Primary anastomosis may be done if no septic shock present, but Hartman procedure remains popular.

• Examine specimen before closing abdomen—if malignancy found, wider resection can be performed if patient is stable.

Diverticulitis – Perforation

• Stage IV: Generalized fecal peritonitis—

– Most devastating type of perforation with greatest mortality rate.– Abdomen may reveal distention, tenderness, guarding, or rigidity.– Leukocytosis will be present.– Abdominal series will usually reveal free air.– Symptoms and signs of peritonitis may be minimal or absent in elderly

or steroid-treated patients.– Rigorous medical treatment is required.– Immediate emergency sigmoid resection is required.– General surgical principles described in prior slide apply.

• If this septic process erodes into adjacent structures, a fistula may result.

Colovesical Coloenteric Colovaginal

Diverticulitis – Fistula

BladderFistula Small bowelFistula VaginalFistula

PelvicAbscess

Diverticulitis – Fistula

• Fistulas—

– Peridiverticular abscesses can progress to form fistulas between the colon and surrounding structures in up to 10-20 percent of patients with diverticulitis.

– Colovesical fistulas (colon to bladder) are the most common variety and require surgery for treatment.

– Colocutaneous, colovaginal, and coloenteric fistulas also occur.

– Fistulas involving the bladder are more common in men, since in women the uterus is interposed between the colon and the bladder.

Diverticulitis – Fistula Symptoms

• Colovesical fistulas—– Symptoms include dysuria, frequency, hematuria, lower

abdominal pain, pneumaturia, and fecaluria.

• Colocutaneous fistulas—– Symptoms include stool passing through fistula, fever, mass,

obstruction, skin excoriation, rectal bleeding, or peritonitis.

• Colovaginal fistulas—– Symptoms include abdominal pain, discharge of pus, stool, or

flatus through the vagina; findings may reveal an opening usually in the apex of the vagina or a pelvic mass.

• Coloenteric fistulas—– Symptoms include abdominal pain and diarrhea; occasionally an

ischioanal abscess will present.

• Treat by resecting offending organ of origin—sigmoid!

Diverticulitis – Hemorrhage

• Hemorrhage—– Not due to an inflammatory process.– Massive diverticular bleeding appears due to chronic injury to

the vasa recta—rupture can occur at the apex or the neck.– Bleeding stops spontaneously in 70% of patients.– Of those patients, rebleeding occurs in 25%.– Colonoscopy and bleeding scans may help identify site.– Various indications for operation have been presented.– Appropriate segmental resection should be performed if site has

been previously identified.– Intraoperative colonoscopy may be of further help.– If no site can be identified, total colectomy with ileorectal

anastomosis should be performed.

Diverticulitis – Obstruction

• Obstruction—

– Intestinal obstruction is uncommon in diverticulitis, occurring in only approximately 2 percent of patients.

– Small bowel obstruction is most frequent and occurs when the small bowel twists as a result of intra-abdominal adhesions .

– This small bowel obstruction is often self-limited and responds to conservative therapy.

– The colon can also become obstructed itself by luminal narrowing caused either by chronic inflammation with progressive fibrosis and stricture of the colonic wall or by acute compression secondary to abscess, both requiring surgical resection, and Hartman’s procedure is usually performed.

Diverticulitis – Treatment

• The severity of the inflammatory and infectious processes as well as the underlying health of the patient determine the appropriate treatment for patients with diverticulitis.

• Patients with uncomplicated diverticulitis who are clinically stable and are able to tolerate fluids may undergo outpatient treatment with broad-spectrum antibiotics and diet restriction.

• Hospitalization is recommended if patients show signs of significant inflammation, have complications of diverticulitis, are unable to take oral fluids, are elderly, or have significant co-morbid conditions.

• These latter patients should be placed on bowel rest, treated with intravenous fluids and intravenous antibiotics.

Diverticulitis – Treatment

• Surgery—– Surgery typically is not indicated after an uncomplicated first

episode because only 7 to 35 percent of those patients experience a recurrent episode.

– Younger patients (<50 yrs) with subsequent CT evidence of severe diverticulitis should be offered elective colectomy.

– After a second episode, the probability of a third episode increases to 50 percent, and subsequent attacks are less likely to respond to medical therapy and have a higher mortality and/or morbidity rate.

– Complicated episodes are suggestive of “more to come” and surgery should likely be considered.

– 15 to 30 percent of patients may require surgery during hospital admission because of lack of response to treatment or because of development of complications.

Diverticulitis – Treatment

• Surgery—

– Several surgical options are available, including resection with primary anastomosis, resection with colostomy and closure of the rectal stump (Hartman pouch), resection and anastomosis with protective transverse colostomy or ileostomy, and transverse colostomy with drainage.

– The surgery may be performed either by open, laparoscopic, hand-assisted, or combined techniques.

Diverticulitis – Treatment

• Surgery—

– The entire thickened contracted segment, not just the inflamed segment, should be resected.

– An anastomosis should not be performed in thickened bowel.– Every diverticulum does not require resection, but no diverticulum

should be involved with the anastomotic line.– Some diverticula may be hidden by the appendices epiploicae.– The lowest incidence of recurrence has been found when the

descending colon was anastomosed to the upper rectum.– The lowest incidence of strictures has been found when the

inferior mesenteric artery was preserved.