Diverticular disease - definitions

ƒ Diverticulosis - presence of Benign Colorectal diverticula Conditions ƒ Diverticulitis - presence of inflammation and infection Nishit S. Shah, MD ƒ Diverticular disease - full spectrum VCU School of Medicine of disease

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Diverticulosis – Diverticulosis – radiological endoscopic appearance appearance

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Clinical presentation Clinical presentation ƒ Diverticulosis – incidental finding; ? IBS ƒ Diverticulitis – related to spectrum of disease ƒ Diverticulitis – related to spectrum of –history disease – LLQ pain ( 93 - 100%); ? RLQ pain if sigmoid – abdominal tenderness – localized vs. diffuse redundant – fever ( 57 - 100%) – high temp if peritonitis/abscess – fever – more common with complicated disease – nausea / vomiting – not common – abdominal mass – LLQ; up to 1/3 of patients – change in bowel habit – ? systemic signs – sepsis, circulatory – urinary sx - ? inflammation near bladder; ? fistula dysfunction – previous attacks – rectal bleeding not common; not massive 5 6

1 Investigations Investigations - radiology

ƒ Routine laboratory tests –CBC - WBC (69-83%) ƒ CT scan – diagnostic modality of –UA choice ƒ Radiological studies – CT findings –plain AXR • pericolic fat streaking (88%) • ? Ileus, ? dilated colon, ? free air • diverticula (73%) ƒ If diagnosis is clear no further tests are needed • wall thickening in uncomplicated disease • abscess/phlegmon – BUT 34-67 % misdiagnosis rate

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Investigations - radiology Classification ƒ Uncomplicated – symptomatic uncomplicated 85% – recurrent symptomatic ƒ Complicated – 15% – hemorrhage – uncommon in diverticulitis – stricture Æ LBO –fistula – SBO – post-inflammatory adhesions – perforation – abscess, peritonitis

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Uncomplicated diverticulitis - Acute diverticulitis – medical management indications for operation ƒ Treatment – bowel rest + antibiotics ƒ 2 episodes of uncomplicated – outpatient if – diverticulitis requiring hospitalization • mild disease – no systemic ƒ 1 episode of uncomplicated symptoms/signs diverticulitis in immunocompromised • able to tolerate limited diet patient • if not immunosuppressed – steroids, ? diabetes – including diabetes, AIDS, renal failure – inpatient if – ƒ 1 episode of complicated • significant pain diverticulitis

• localized peritoneal signs 11 12

2 Management of complicated CT Scan diverticulitis ƒ Fistula – 12% of pts ƒ Colovesical most common – 65% – 2/3 have urinary sx – most commonly pneumaturia – dx – CT, BE, cystoscopy, urine culture – tx – colon resection + 1° anastomosis • enbloc resection if ? malignant etiology ƒ Colovaginal – 2nd most common – virtually never occurs with uterus in situ ƒ Also – colocutaneous, coloenteric, coloureteric 13 14

CT Scan CT Scan

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Contrast CT Scan - air in bladder Enema

SigmoidSigmoid Colon Colon

Vagina Vagina

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3 Lower GI Bleeding Lower GI Bleeding

ƒ Upper vs Lower – distal to ligament of Treitz – diverticulosis – not –itis – usually proximal – angiodysplasia – usually on right – cancer, IBD, ischemic, radiation

Diverticulosis 19 20

Lower GI Bleeding Lower GI Bleeding

ƒ Resuscitate – isotonic fluids/blood – type and cross, r/o coagulopathy ƒ R/O upper GI source – NG, EGD ƒ R/O anorectal source – ano- proctoscopy

Angiodysplasia 21 22

Lower GI Bleeding Pseudomembranous colitis ƒ Diagnosis – colonoscopy ƒ Caused by gram +ve anaerobe – bleeding scan (0.1 cc/min) – C. difficile – angiography (0.5 cc/min) ƒ Prior Abx use; esp in ƒ 75 % stop spontaneously immunosuppressed ƒ Surgery - if massive (> 6U PRBCs/24 h), ƒ Tetrad – fever, watery diarrhea, if unable to stop through c-scope, angio. abdominal pain,  WBC – try to localize in order to perform “guided” resection – if unable to localize Æ subtotal colectomy 23 24

4 Pseudomembranous colitis Pseudomembranous colitis

ƒ Toxins A and B – B detected in ELISA ƒ Tx – stop Abx, PO (or IV) MNZ, PO ƒ Dx – stool culture for type B cytotoxin; vancomycin (only works enterally) flex sigmoidoscopy Æ yellow plaques ƒ 3-20% develop toxic state – 65% of ƒ Differ dx – IBD ( more chronic hx ), these will require surgery ischemic colitis (bloody diarr)

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Ulcerative colitis Ulcerative colitis

ƒ Diffuse inflammatory disease limited ƒ Always has rectal disease to (sub)mucosa of colon and rectum ƒ “Backwash ileitis” in 10% ƒ etiology unknown ƒ Signs - non-specific in non-fulminant ƒ Sxs – diarrhea, abdom pain – not disease. If toxic – abdominal severe, rectal bleeding distension. If perforation – peritonitis ƒ 10 % may be toxic/fulminant

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Ulcerative colitis - diagnosis Ulcerative colitis - diagnosis

ƒ BE – in acute phase – edema, ulceration, ? thumb-print – in chronic phase – fibrosis, loss of haustra, pattern, shortening especially of L side, strictures ƒ Endoscopy – loss of normal vascular pattern; contact bleeding; granularity; superficial ulcers,pseudopolyps – presence of disease from the dentate line cephalad in continuity with proximal involvement

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5 Ulcerative colitis - diagnosis Ulcerative colitis

ƒ Relationship to carcinoma –  risk with pancolonic disease, age of onset, duration (> 10y), active disease/severity – incidence of CRC in UC - 2 - 5% – most common site - rectum

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Ulcerative colitis - treatment Ulcerative colitis

ƒ Indications for surgery ƒ Medical treatment – fulminant (toxic) UC – routes of delivery: topical; oral; intravenous – toxic megacolon – medications – frank perforation – usually with toxic • 5-ASA compounds dilatation • corticosteroids – refractory to medical tx – most common • immune-modulating agents - – extracolonic manifestations – PG, EN, LFT Azathioprine and 6-MP; Cyclosporine abnorm., joint/eye abnorm – malignant degeneration – development of dysplasia 33 34

Ulcerative colitis

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Crohn’s disease Crohn’s disease - diagnosis

ƒ Chronic, relapsing, transmural, ƒ History and Physical segmental, granulomatous disease ƒ UGI – strictures, dilated areas, that can affect any portion of GI tract thickened bowel ƒ Etiology unknown ƒ BE – thickened bowel, ulcers, ƒ Sxs–diarrhea (non-bloody), abdom longitud fissures pain, fever, malaise, malnutrition, anorectal ƒ Most common site ileocolic

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Crohn’s disease - diagnosis

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7 Crohn’s disease - diagnosis Crohn’s disease - diagnosis

ƒ Endoscopy – normal rectum in 40-50%, aphthous ulcers, fissures, cobblestoning, patchy ƒ Operative – thickened mesentery, creeping fat, serositis, thickened bowel

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Crohn’s disease - diagnosis Crohn’s disease - diagnosis

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Crohn’s disease - complications Crohn’s disease - treatment

ƒ Medical treatment ƒ Obstruction – routes of delivery: topical; oral; intravenous ƒ Perforation Æabscess, Æ fistulas – medications ƒ Carcinoma – less common vs UC • 5-ASA compounds ƒ Toxic megacolon – in Crohn’s colitis • corticosteroids • antibiotics – MNZ, ciprofloxacin • immune-modulating agents - Azathioprine and 6-MP; Cyclosporine; infliximab (anti-TNF-α)

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8 Crohn’s disease - treatment Anorectal disorders ƒ Indications for surgery – in 70-75 % ƒ Hemorrhoids of pts – anatomy – stricture , chronic obstruction, • 3 sinusoid cushions, not veins. LL, RAL, – abscess or fistula, RPL. Functions – cushion, lining – bleeding – etiology – extracolonic complications - PG, PAN, • constipation; pregnancy; ↑ IS dysfunc; uveitis aging. Not portal HTN – disease intractability – most common – classification – emergency indications • external (distal to dentate line); internal – remember – SURGERY NOT CURATIVE (proximal to dentate line) , graded 1-4 (cf UC) 49 50

Hemorrhoids Anorectal disorders ƒ Hemorrhoids – symptoms • pain, mucus discharge, bleeding –exam • rectal, anoscopy. if 40+ y consider full colon evaluation – treatment • non-operative –diet (↑ fibre), soaking •operative – banding, sclerotx, hemorrhoidectomy 51 52

Anorectal disorders Anal fissure

ƒ Fissure – tear Æ pain, rectal bleeding – usually in midline – esp postr midline – if lateral - ? AIDS, Crohn’s, lymphoma, STD ƒ Treatment – non-operative : high-fiber, soaks, stool softeners • NTG ointment – relaxes sphincter spasm – operative – lateral sphincterotomy, fissurectomy

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9 Anorectal disorders Perirectal abscess

ƒ Perirectal abscess – usually cryptoglandular – also Crohn’s, actinomycosis, TB ƒ Classification – perianal, ischiorectal, intersphincteric, supralevator ƒ Pain, swelling, drainage ƒ Treatment – I/D

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Fistula-in-ano Anorectal disorders

ƒ Fistula-in-ano – usually sepsis arising at the dentate line ƒ Classification – inter- (70%), trans-, supra-, extra- sphincteric – Goodsall’s law ƒ Treatment – define anatomy – based on relation to sphincters

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Anorectal disorders Hidradenitis suppuritiva

ƒ Hidraadenitis suppuritiva – chronic recurring inflammatory condition of apocrine glands and adjacent skin / con. tissue ƒ Presents – nodule Æ abscessÆ sinuses ƒ Treatment – perianal hygiene, I/D, WLE

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10 Anorectal disorders Anorectal disorders

ƒ Pilonidal disease ƒ Rectal prolapse – obstructed hair • ? etiology follicle in sacrococcygeal area –deep cul-de-sac, weak pelvic floor, ƒ Abscess Æ Sinus redundant sigmoid, patulous anal sphincter ƒ Treatment – I/D, marsupialization, – associated with incontinence / constipation WLE – treatment – perineal; abdominal

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Rectal prolapse Rectal prolapse

Hemorrhoids 63 64

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