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GIHEP Surgery - Diverticular Disease (Complications (acute diverticular…
GIHEP Surgery - Diverticular Disease
Intro
acquired outpouchings of sac-like mucosal projections through the colon wall
just mucosa, not thick
breach in muscle layer - taenia coli
typically affect sigmoid colon, buy may affect any part of colon
common - affects 30% of 60 y/os
disease of western living
a/w constipation + increased colonic pressure
can also cause bleeding (vasa recta in close proximity) + constipation (faecolfiths can get stuck)
endoscopy can be hazardous - risk of perforation of you mistake a diverticulum for the lumen
Diverticulosis vs diveriticulitis
both are types of diverticular disease
osis - mere presence of outpouchings - patient usually asymp + dx is usually an incidental find
itis
inflamm of an outpouching
narrows lumen + hence causes symptoms
LIF pain + tenderness (guarding/rebound)
diarrhoea/constipation
PR bleeding
nausea + vomiting
fever
tachycardia + HTN
Complications
acute diverticular bleed
usually painless
spontaneous, no prodromal symptoms
large vol of blood loss (risk of haemodynamic instability)
bright red
due to rupture of peridiverticular submucosal vessel
risk = 15%
risk of rebleed after single bleed = 25%
risk of rebleed after 2 bleeds = 50%
85% stop spontaneously
patients usually old + frail
perforation +/- peritonitis
obstruction
fistulae
colovesicle (between colon + bladder)
colouterine
colovaginal (esp post-hysterrectomy)
stricture
pericolic/paracolic abscess
majority can be managed conservatively
inflamm txed with antibiotics (controversy)
surgery reserved for emergencies + failure of other therapies
acute diverticulitis
Hinchey classification
1A: paracolic phlegmon (solid soft tissue inflamm abscess)
1B: pericolic/mesenteric abscess
2: diverticulitis with walled off abscess
3: purulent peritonitis (perforated abscess cavity)
4: faeculent peritonitis (leaking bowel contents)
Tx
uncomplicated (Hinchey 1/2/3)
start medical
IV antibiotics + fluids
bowel rest
analgesia
consider radiological guided drainage of abscess
consider surgery if medical management fails
complicated
laparoscopy + washout
segmental colectomy
if patient unwell or there is a perforation - Hartmann's procedure
surgical resection of rectosigmoid colon
closure of anorectal stump - still have anal canal
end colostomy
primary anastomosis possible