DIVERTICULOSIS
INCIDENCE AND EPIDEMIOLOGY
• Among western populations, diverticulosis of the
colon affects nearly one-half of individuals over
age 60 only 20% of patients with diverticulosis
develop symptomatic disease.
• Diverticulosis is rare in underdeveloped
countries, where diets include more fiber and
roughage.
ANATOMI AND PATHOPHYSIOLOGY
Diverticular disease is a disorder where there is
herniation of mucosal / submucosal and serous tunica
coated only on the location of a weak colonic wall.
Two types of diverticula occur in the intestine :
1. True A true diverticulum is a saclike herniation of
the entire bowel wall congenital
2. Pseudodiverticula A pseudodiverticulum involves
only a protrusion of the mucosa through the
muscularis propria of the colon acquired
The most common type of diverticulum affecting the
colon is the pseudodiverticulum
• Diverticula commonly affect the sigmoid colon;
only 5% of persons exhibit pancolonic
diverticula. This anatomic restriction may be a
result of the relative high-pressure zone within
the muscular sigmoid colon.
• Diverticulitis or inflammation of a diverticulum,
is related to the retention of particulate material
within the diverticular sac and the formation of a
fecalith. Consequently, the vasa recti is either
compressed or eroded, leading to either
perforation or bleeding.
PATHOGENESIS
• The cause is a lack of fiber and a weak area in
the colon wall
• Physiology
High-fiber foods more solid and large stool
shorten fecal transit time in the colon
reduce the intraluminal pressure prevents the
emergence divertikel.
• Less fiber consumption decreased fecal mass
into a small and hard colonic transit time
more slowly absorption of more water and
decrease output increased pressure within the
colon to push the mass of feces excessive
colonic segmentation.
• Segmentation of the colon due to excessive
contraction of circular muscle to stimulate the
colon wall and lumen contents of the material in
passase colon is one of the causes of diverticular
disease.
• Increasing segmentation of occlusion will occur
at both ends of the segment so that intraluminal
pressure increases excessively and herniation
occurred and formed divertikel.
• Another thing that affects in divertikel are age
factors which decrease the mechanical pressure
of the colon wall as a result of changes in
collagen structure of the intestinal wall.
• Several environmental factors are considered
influential is the excessive consumption of meat
and foods high in fat.
• Bleeding from colonic diverticulum causing
hematokezia most in patients> 60 years old.
• The risk increases when patients have history of
hypertension, atherosclerosis, and the use of
NSAIDs continues - and again.
Clinical Symptoms
• Asymptomatic in 80% patients.
• There was no fever or leukocytosis when no
inflammation. General conditions are not
disturbed and there are no systemic signs.
• Attacks of pain, and diarrhea obstipasi by
impaired motility of the sigmoid.
• Examination found a mild local tenderness and
palpable sigmoid can often be as solid
structures.
• Acute diverticulitis: malaise, fever, pain and
tenderness in the left iliac fossa with or without
a palpable mass and abdominal distension
Divertikel most frequent bleeding in the form of
massive haemorrhage which occurred arrive -
arrived without any symptoms of abdominal
pain and 70-80% stop spontaneously.
Herniation of the only coated with a thin layer of
mucous that may be susceptible to chronic
inflammation caused by irritation of the colonic
contents resulting in rupture and hemorrhage
Supporting Examination
• X-rays looked divertikel and thickening of the
wall which causes narrowing of the lumen.
• Abdominal ultrasound images found colonic
wall thickening and cystic mass.
• CT scans can be found in the colon wall
thickening> 4 mm, inflammation, and make
sure it's not appendicitis or an abscess.
• Colonoscopy, especially if there is bleeding to
rule out colon carcinoma
Barium enema
Colonoscopy
Complication
Hinchey classification of diverticulitis
1. Stage I: perforated diverticulitis with a confined
paracolic abscess.
2. Stage II: perforated diverticulitis that has closed
spontaneously with distant abscess formation.
3. Stage III: noncommunicating perforated
diverticulitis with fecal peritonitis (the diverticular
neck is closed off and therefore contrast will not
freely expel on radiographic images).
4. Stage IV: perforation and free communication with
the peritoneum, resulting in fecal peritonitis.
Hinchey classification of
diverticulitis
TREATMENT
1. Medical Management
Asymptomatic diverticular disease discovered
on imaging studies or at the time of
colonoscopy is best managed by diet
alterations. Patients should be instructed to
eat a fiber-enriched diet that includes 30 g of
fiber each day.
Supplementary fiber products such as
Metamucil, Fibercon, or Citrucel are useful.
The patient should also be instructed to avoid
nuts and popcorn, which may obstruct the
lumen of a diverticulum.
• Symptomatic diverticular 7-10 days antibiotics
and bowel rest.
• Recommended trimethoprim / sulfamethoxazole
or ciprofloxacin and metronidazole for aerobic
gram-negative rods and anaerobic bacteria.
• Ampicillin is also recommended for
Enterococcus.
• As an alternative, single-agent therapy with third
generation may penicilin
2. Surgical Management
▫ Given to patients who have a minimum of 2x
divertikultis attack and needed hospital
treatment or to patients who do not give repson
against drugs - drugs.
▫ The purpose of operations to avoid sepsis,
prevent complications such as fistul,
obstruction, removing the diseased colonic
segment, and restore the continuity intestinum
• Hinchey stages I and II disease are managed
with percutaneous drainage followed by
resection with anastomosis about 6 weeks later.
• Percutaneous drainage is recommended for
abscesses 5 cm with a well-defined wall that is
accessible.
• Contraindications to percutaneous drainage are
no percutaneous access route,
pneumoperitoneum, and fecal peritonitis.
• Urgent operative intervention is undertaken if
patients develop generalized peritonitis, and
most will need to be managed with a Hartmann's
procedure.
• Hinchey stage III disease is managed with a
Hartman's procedure or with primary
anastomosis and proximal diversion. If the
patient has significant comorbidities, making
operative intervention risky, a limited procedure
including intraoperative peritoneal lavage
(irrigation), omental patch to the oversewn
perforation, and proximal diversion of the fecal
stream with either an ileostomy or transverse
colostomy can be performed.
The surgical management of
complicated diverticular disease
(1) proximal diversion of the fecal stream with an
ileostomy or colostomy and sutured omental patch with
drainage,
(2) resection with colostomy and mucus fistula or
closure of distal bowel with formation of a Hartmann's
pouch,
(3) resection with anastomosis (coloproctostomy), or
(4) resection with anastomosis and diversion
(coloproctostomy with loop ileostomy or colostomy).
Laparoscopic techniques have been employed for
complicated diverticular disease; however, higher
conversion rates to open techniques have been reported
Methods of surgical management of complicated diverticular disease. (1)
Drainage, omental pedicle graft, and proximal diversion. (2) Hartman's
procedure. (3) Sigmoid resection with coloproctostomy. (4) Sigmoid resection
with coloproctostomy and proximal diversion .
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