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Acute Diverticulitis.pptx
- 1. Acute Diverticulitis 2022/10/28 Presented by:Dra Kou Pou Kuan ( IC of Emergency Medicine ) Supervisor: Dra Ng Wai Lon
- 2. Content Case Whatis it? How to diagnosis? How to assessment? What is the plan?
- 3. Case •60y/F, Hxof Pulmonary tuberculosis sequelae •Denied smoking and drinking alcohol. •Mother had cholangiocarcinoma Complain • Fever and lower abdominal pain for 1 week • Pain: persistent, dullness, no radiating pain • Frequency with urgency of urination • No vomiting or nausea, no tenesmus, no hematochezia • Bowel habit was normal Present illness: 21/02/2022
- 4. 1 Physical examination(ER): T: 38.2,Bp: 108/74mmHg, P 107bpm, SpO2 98%(RA) APC: No ralse, HR regular ABD: One surgical scar is visible in the middle of the abdomen. Soft, flat, tenderness on lower middle abdomen, no rebound tenderness, McBurney point(-), bowel sound normal active, bilateral costal spine angle percussion was negative Digital rectal exam: Yellowish stool, no mass
- 5. 1 Comp. Exam (21/02/2022) Na134, K 3.6, Cl 103 AST/ALT: 20/14 Hb 14.5g, WBC 23x10^9/L(Neu 88.2%), Platelet 384 CRP: 9.19, PCT 0.14 Urine II: Normal Blood and urine culture: Negative CT of the Abdomen and Pelvis with Contrast Diverticulitis of sigmoid colon with peri-diverticular abscess(5.2x6.1x5.7cm, air locules), inflammatory process involving the bladder and the adjacent ileum
- 6. 1 Impression: Acute sigmoid diverticulitiswith peri-diverticular abscess Flagyl 500 mg q8h + Rocephine 1g q12h Treatment:
- 7. Diverticulum “Bulges” in largeintestine due to weakened bowel walls True: All 3 layers (Mucosa, submucosa, muscular layer) (eg, Meckel diverticulum) Pseudo: Mucosa, submucosa (Zenker diverticulum) Diverticulitis Gastrointestinal disorder involving inflammation of diverticula (Fecolith across divericular)
- 8. Epidemiology ● Mortality andMorbidity - 15- 25% require surgical therapy - 7.7%( If peritonitis is present) ● Age( increases with age) ● Race - Asians : Right sided diverticulitis - Western: Left sided diverticulitis ● Common: Sigmoid colon Western Countries Location • Left colon involvement 95% • Left plus right colon 5% • Right colon only: Rare Type • Pseudo - diverticula Prevalence • Increases with age • Number of diverticula increases with age Main complication • Diverticulitis Asian Countries Location • Right colon involvement 90% • Left plus right colon 10% • Left colon only: Rare Type • True diverticula Prevalence • Stable with age • Number of diverticula stable with age Main complication • Bleeding Diverticular disease: Epidemiology and management. Adam V Weizman, MD, FRCPC1 and Geoffrey C Nguyen, MD PhD FRCPC. Can J Gastroenterol. 2011 Jul; 25(7): 385–389.
- 9. Pathophysiology ● Increased intraluminalpressure -Associated with lack of dietary fibre ● Degenerative changes in colonic wall -Usually at point of entry of terminal arterial branches (Branch of inferior mesenteric artery) where serosa is weakest -Associated with weakening of collagen structure with age Diverticular Disease: An Update on Pathogenesis and Management. Mona Rezapour, Saima Ali, and Neil Stollman. Gut Liver. 2018 Mar; 12(2): 125–132. 2017 May 12. doi: 10.5009/gnl16552
- 10. Risk factor • IncreasingAge • Diet- Low in dietary fiber and high in refined carbohydrates • Lack of vigorous physical activity • Smoking • Hight BMI • NSAID use
- 11. Clinical Manifestations ● Pain -Typically located in left lower quadrant - Constant pain, may be diffuse - Right sided (Congenital?) ● Fever - Almost invariably present - High grade fever and sepsis ● Bowel Habit change, rectal bleeding ● Nausea & Vomiting ● Urinary urgency, Frequency, Dysuria
- 12. Complicated diverticulitis ● Localizedsigmoid thickening (>5 mm) ● Inflammation of pericolic fat ● Abscess (phlegmon) ● Frank(Free) perforation ● Obstruction ● Fistulization ● Large phlegmon ● Peritonitis Severe Diverticulitis Mild Diverticulitis Classification---CT scan Uncomplicated diverticulitis
- 13.
- 14.
- 15. Inpatient Vs Outpatient ●Acute Complicated diverticulitis ● Acute uncomplicated diverticulitis PLUS 1) Sepsis, 2)Microperforation or phlegmon, 3) Immunosuppressed patient or Significant comorbidities, 4) Fever > 39C, 5) Signifiant leukocytosis, 6) Age >70 years, 7) Intolerance of oral intake, 8) Severe abdominal pain/ peritonitis, 9) Failed outpatient treatment Uncomplicated Diverticulitis without other associated issues = outpatient treatment
- 17. Oral antibiotic(7-10 days) ●Ciprofloxacin(500 mg q12h) + Metronidazole (500 mg q8h) ●Levofloxacin (750 mg daily) + Metronidazole (500 mg q8h) ●Trimethoprim-sulfamethoxazole (160mg/800 mg q12h) plus metronidazole (500 mg q8h) ●Amoxicillin-clavulanate (875 mg/125 mg) q8h or Augmentin XR q12h ●Moxifloxacin (400 mg daily; use in patients intolerant of both metronidazole and beta-lactam agents)
- 18.
- 19.
- 21. Emergency surgery foracute diverticulitis Frank perforation(Hinchey III and IV) (1C) Microperforation with peritonitis (1C) Develop ileus or bowel obstruction (1C) Nonoperative management of acute diverticulitis fails (1C)
- 22.
- 23. Unstable Damage control surgery:“Iethal triad”---metabolic acidosis, hypothermia, and increased coagulopathy
- 24.
- 25. Laparoscopic lavage isnot superior to sigmoidectomy for the treatment of purulent perforated diverticulitis.
- 26. Technical considerations The extentof elective resection should include the entire sigmoid colon with margins of healthy colon and rectum. Non inflammed tissue should be used for anastomosis Not necessary to remove all diverticula A leak test of the colorectal anastomosis should be performed
- 27. Long term management Colonoscopy(6-8 weeks) - Complicated diverticulitis with imaging abnormalities or atypical courses Abdominopelvic computed tomography imaging may be repeated to rule out a new complication Cancer, Chronic smoldering diverticulitis
- 28. After afirst occurrence of acute diverticulitis, the 5-year recurrence rate is 20%. The risk of further complications and need for emergency surgery < 5 % 30% remain asymptomatic 20% with chronic abdominal pain
- 29. • Antibiotic 1week • CT of the Abdomen and Pelvis with Contrast The abscess in the pelvic is diminished in size( 5.2x6.1x5.7->3 x 3.8 cm) • Soft diet 28/02 • Antibiotic 2 weeks • Fever Tmax 38C, PE: normal • WBC 8.6x 10^9/L, CRP 0.38 • Colonscopy: Multiple tiny diverticular at Sigmoid 07/03 Back to Case 24/02 • Admitted • Flagyl 500 mg q8h + Rocephine 1g q12h • Liquid diet • IR doctor refuse drainage 25/02 08/03 Diagnostic laparoscopy
- 30. 29/03 • CT ofthe Abdomen and Pelvis with Contrast: Normal • WBC 10 x 10^9/L(Neutro 83%), CRP 1 mg/dL • General diet, Change Flagyl+ Fortum • Discharge • Remove drainage 1 5 /0 3 • Fever, wound infection, Drainage: 168ml, clear. • WBC 19.3 x 10^9/L(Neutro 83%), CRP 3.58 mg/dL • CT of the Abdomen and Pelvis with Contrast No focal fluid collection throughout the abdomen and pelvis. • Wound culture Escherichia coli • Fasting with TPN, Change Meropenem 1g q8h 29/03 4/4 22/03 • Drainage: 10 ml-> Liquid diet Case
- 31. Take home messages •Hinchey classification guide the treatment • Antibiotic consider withholding in mild cases • Surgery is individualized • Unstable: Hartmann's procedure • Follow up colonoscopy
- 33. Reference ● Crowe FL,Balkwill A, Cairns BJ, et al; Million Women Study Collaborators; Million Women Study Collaborators. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut. 2014;63:1450–1456. ● Aune D, Sen A, Leitzmann MF, Tonstad S, Norat T, Vatten LJ. Tobacco smoking and the risk of diverticular disease - a system_x0002_atic review and meta-analysis of prospective studies. Colorectal Dis. 2017;19:621–633. ● Suhardja TS, Norhadi S, Seah EZ, Rodgers-W ilson S. Is early co_x0002_lonoscopy after CT-diagnosed diverticulitis still necessary? Int J Colorectal Dis. 2017;32:485–489. ● Bolkenstein HE, van de Wall BJ, Consten EC, van der Palen J, Broeders IA, Draaisma WA. Development and validation of a d ia g n o s t i c p r e d i c t i o n m o d e l d is t i n g u i sh i n g c o m p l i c a t e d f r o m u n c o m p l i ca t e d d i ve r t i c u l i t i s . S c a n d J G a s t r o e n t e ro l . 2018;53:1291–1297.25. ● S tollman N, Smalle y W, Hirano I; A GA Inst itu te Clin ica l Guide_ x0002_line s Comm it tee . Ame rican Gast roente rolo gical Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015;149:1944–1949. ● Mege D, Yeo H. Meta-analyses of current strategies to treat uncomplicated diverticulitis. Dis Colon Rectum. 2019;62:371– 378. ● Emile SH, Elfeki H, Sakr A, Shalaby M. Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis, and meta-regression of predictors of treatment failure. Tech Coloproctol. 2018;22:499–509. ● Lambrichts DPV, Bolkenstein HE, van der Does DCHE, et al. Multicentre study of non-surgical management of diverticulitis with abscess formation. Br J Surg. 2019;106:458–466.
Editor's Notes
- #2 Good morning, every doctor, this is KOU POU KUAN, i am a emergency medicine IC, my tutor is Dr Ng Wai Lon, today the presentation topic is Acute Diverticulitis, thank you pay attention on my presentation and Dr Ng gave me professional advice for this topic.
- #3 My topic is mainly in the treatment part
- #4 00610196.9 This is a 60-year-old female with pass history of Pulmonary tuberculosis on 2010, this time she presented fever with persistent, dullness lower abdominal pain for 1 week, associated with Frequency with urgency of urination she had consulted KWH, she was suspected urine tract infecetion, and given empirical antibiotic , but the symptoms were no improved. Thus she consulted our emergency room.
- #5 On arrival, PE found fever with abdominal tenderness on the lower middle abdomen without Guarding and digital rectal exam just found yellowish stool.
- #6 the blood analysis found inflammatory markers was elevated, urine analysis was normal, CT was Diverticulitis of sigmoid colon, peri-diverticular abscess with air locules, involved bladder,
- #7 Thus she was given empirical antibiotic with Flagyl and Rocephine under impression of Acute sigmoid diverticulitis with peri-diverticular abscess, admitted ward for fathrather managment
- #8 a diverticulum is a sac like protrusion or herniation of the mucosa, when the inner layers of the colon push through weaknesses in the outer muscular layers. Diverticulum can be either false or true. In general, the gastrointestinal tract consists of the submucosal, mucosal, and muscular layers. A true diverticulum contains all layers of the gastrointestinal tract wall. (The most common true diverticulum is Meckel's diverticulum wich is congenital defect of the small intestine). A false diverticulum only involves the submucosa and mucosa, do not contain the muscular layers or adventitia. ( Zenker diverticulum is a false diverticulum that develops in the upper posterior esophagus. ) Thus A true diverticulum is congenital, see in infants,it is commonly accompanied by gross or microscopical perforation. the false diverticulum is acquired, see in adult population. The term “diverticulitis” indicates the inflammation of a diverticula, which is commonly accompanied by gross or microscopical perforation.
- #9 The incidence of diverticular disease increases with age and is present in up to two thrids of the population aged over 85 years. The mean age at presentation appears to be about 60 years. In men there's a higher incidence in younger age groups but in women it's higher in older age groups. Left-sided diverticular disease (particularly the sigmoid colon) is most common in the West, while right-sided diverticular disease is more prevalent in Asia and Africa,usually consists of a single or a few true diverticular in the caecum or ascending colon.
- #10 The development of colonic diverticulum is thought to be a result of raised intraluminal colonic pressures, dysfunctional peristalsis, and defects of the bowel wall. such as constipation or increasing abdominal girth in obesity, protrude at areas of potential weakness, Usually at point of terminal arterial branches and Associated with weakening of collagen structure with age. On the other hand, demonstrated associations between diverticulosis and diets that are low in dietary fiber and high in refined carbohydrates.Low intake of dietary fiber results in less bulky stools that retain less water,causing constipation, this raises intracolonic pressure and increases gastrointestinal transit time; these factors make evacuation of the colonic contents more difficult. AT the same time, Colonic diverticula have narrow necks that can be easily obstructed by fecal matter, which by irritation of the mucosa causes low-grade inflammation, congestion and further obstruction. It may lead to bacterial overgrowth and local tissue ischemia, vascular compromise, and perforation.
- #11 except lower dietary fiber, Other modifiable risk factors include physical inactivity, obesity, alcohol dependence , smoking, and treatment with nonsteroidal anti-inflammatory drugs.
- #12 the clinical presentation of acute diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence or abscence of complications. classic triad of left lower abdominal pain, fever, and leukocytosis. Other manifestations inculde vomitting, urinary symptoms and change in bowel habits. The most common sign is tenderness around the left side of the lower abdomen. Right-sided diverticulitis of the cecum or ascending colon may present with right lower abdominal pain, which may be confused with acute appendicitis. Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.
- #13 The colonoscopy are contraindicated in the acute diverticulitis due to the risk of perforation, thus The CT scans is recommended be the glod standard as the initial imaging by international guidelines, it can assess disease severity and presence of complications. According to Ct result, acute diverticulitis can be classified as uncomplicated or complicated. The feature of uncomplicated acute diverticulitis includes pericolic fat stranding due to inflammation, colonic diverticula, bowel wall thickness of more than 5 mm, the complicated acute diverticulitis includes Abscess, Frank perforation, Obstruction, Fistulization or Peritonitis. At the same time, CTcan initially rule out other causes of abdominal pain, such as appendicitis, tubo-ovarian abscess, or Crohn’s disease.
- #14 The acute diverticulitis clinical staging is often based on the Modified Hinchey classification by CT . it classified that into four stage. Patients with stage 1a is confined pericolic inflammation or phlegmon. CT finding: pericolic soft tissue changes, stage 1b is pericolic or mesocolic abscess, CT finding: Ia changes and pericolic or mesocolic abscess, stage II is pelvic, distant intra-abdominal or retroperitoneal abscess, CT finding: Ia changes and distant abscess, usually deep pelvic, stage 3 is peridiverticular abscess rupture cause generalized purulent peritonitis, CT finding: localized or generalized ascites, pneumoperitoneum, peritoneal thickening, stage 4 is generalized fecal peritonitis, CT finding: same as stage III
- #15 On the other hand, Laboratory testing may be helpful when the diagnosis is in question. A hemogram may reveal leukocytosis and a left shift. However, the absence of leukocytosis does not rule out diverticulitis, particularly in immunocompromised, older, and have less severe disease. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice, suggesting that Patients with pain localized to the left lower abdomen, absence of vomiting, and CRP highly are likely to have acute diverticulitis, they have demonstrated the diagnostic and prognostic value of C-reactive protein for patients with acute diverticulitis.the CRP cut off values over 50 mg/L
- #16 The decision of admission is depends on the patient’s clinical status. For Acute Complicated diverticulitis patient must be admitted, For immunocompetent patients who have a mild attack and can tolerate oral intake, outpatient therapy is reasonable, After two to three days outpatient therapy, patients still have persistent or recurrent abdominal pain, fever, or inability to tolerate oral fluids should be admitted for inpatient treatment.
- #17 According the American Society of colon and Rectal Surgeons, American Gastroenterological Association Clinical Practice Guidelines for Management of colonic Diverticulitis. They recommended Patients with uncomplicated diverticulitis without serious comorbidities can be managed initially with pain control and a low-residue liquid diet (i.e., one largely free of indigestible matter), without antibiotics, Patients are reassessed clinically two to three days after the initial presentation. Repeat imaging studies are not indicated unless the patient fails to improve clinically. For inpatient or if symptoms fail to improve despite adequate outpatient therapy, The patient should initially take nothing by mouth. If there is evidence of obstruction or ileus, a nasogastric tube should be inserted. they need Intravenous Broad-spectrum antibiotic(10~14 days), hydration, Pain control, Bowel rest or clear liquid diet, If there is no improvement in pain, fever, and leukocytosis within 2 or 3 days, or if serial physical examinations reveal new findings or evidence of worsening, repeat CT imaging is appropriate, search for complications.
- #18 In outpatient, The oral broad-spectrum antibiotic therapy may including coverage against anaerobic microorganisms. A combination of ciprofloxacin and metronidazole is often used.
- #19 In inpatient low-risk community-acquired intra abdominal infections, we should cover streptococcus, Enterobacteriaceae, and anaerobes. A combination of intravenous ciprofloxacin and metronidazole is often used.
- #20 In high-risk community-acquired intra-abdominal infections, we cover streptococci, Enterobacteriaceae resistant to third-generation cephalosporins, Pseudomonas aeruginosa, and anaerobes. Extended-spectrum β-lactamases-producing organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem should be chosen. Intravenous antibiotics should be continued until the inflammation is stabilized, resolving abdominal pain and tenderness. typically takes three to five days antibiotic. then transition to oral antibiotics (most commonly ciprofloxacin plus metronidazole or amoxicillin-clavulanate) to complete a 10 to 14 day course (inclusive of intravenous and oral antibiotic therapy).
- #21 this treamtment algorithms show that in Hinchey stage 1, less than 4 cm in diameter pericolic abscess without peritionitis or interventional radiologist can not drain it, they don’t necessarily need an operation even they presented distant free air. it can be treated conservatively with bowel rest and broad-spectrum antibiotics for 48 hours . For Hinchey stage 2,the peridiverticular abscesses larger than 4 cm in diameter, observational studies indicate that CT-guided percutaneous drainage can be beneficial. After percutaneous drainage, patients typically improves within 24 to 48 hours. If patients does not improve within that time, Control CT scan to seening progressed and maybe an abscess can be drain or surgery are indicated. Percutaneous drainage may allow for elective rather than emergency surgery, increasing the likelihood of a successful one-stage procedure. If improved, repeat CT after 5 days teatment for assessment. Patients whose abscess cavities contain gross feculent material tend to respond poorly, early surgical intervention is usually required.
- #22 In surgery, the guidline recommend surgeons to adopt an individualized approach, because the risk of further complications and need for emergency surgery is low at 10 % after admission. it is depented on the severity of the disease, age and coexisting conditions, The indications for emergency operative treatment include Hinchey stage 3 or 4, uncontrolled sepsis, uncontained visceral perforation, the presence of a large or undrainable (inaccessible) abscess, and lack of improvement or deterioration within 3 days of medical management. The primary goal of surgery is to obtain source control by removing the perforated colonic segment; the secondary goal of surgery is to restore intestinal continuity,
- #23 In Hinchey stage 3 or 4, the opeartion techniques depends on hemodynamic stability, the degree of peritoneal contamination, acute organ failure, immunosupperssion, combidities, American Society of Anesthesiologists Physical Status and surgeon experience/preference to choose which one operation you are going to do.
- #24 in Unstable patient, Hartmann’s procedure is the first choose, Primary anastomosis is generally contraindicated, Damage control surgery (DCS) is surgical intervention to keep the patient alive rather than correct the anatomy. The principles of DCS is : (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures.
- #25 It is worth noting that Hartmann’s procedure is the first choose in HIgh MPI, immunodeficient, hight ASA, even tough the hemodynamically stable
- #26 Laparoscopic lavage was originally intended for Hinchey III not for Hinchey IV. But in clinical, it is often difficult to exclude fecal peritonitis during the preoperative evaluation. Thus Laparoscopic lavage is not superior to colectomy for the treatment of purulent perforated diverticulitis. in the technique, the resection margins should include healthy colon, don't use the inflamed tissue for anastomosis, a leak test should be performed after the anastomosis, rule out anastomosis leak.
- #27 in the technique, the resection margins should include healthy colon, don't use the inflamed tissue for anastomosis, a leak test should be performed after the anastomosis, rule out anastomosis leak.
- #28 Endoscopically evaluation has been recommended by most international guidelines after resolution of an episode of acute complicated diverticulitis, to confirm the diagnosis and exclude other diseases, such as colon cancer and inflammatory bowel disease. it usually be perfromed after approximately 6 weeks.
- #29 The prognosis is related to age but age alone is not an independent predictor of mortality. In a first occurrence of acute diverticulitis, who are managed conservatively, the recurrence episodes rate is lower in the following 5 years, have 20% patient present chronic abdominal pain after treatment.
- #30 Back to the case, after admission, we consult IR doctor for drainage, but it was rejected because the abscess in deep pelvic and high risk to puncture the artery. Thus keep conservative treatment. After empirical antibiotic 1 week, control abdominal CT found the abscess size was decreased, but she still presented fever even antibiotic was given for 2 weeks, the Colonoscopy noted Multiple tiny diverticular at sigmoid. on 2022/03/08, she performed Diagnostic laparoscopy, during operation, it found the abscess cavity is wrapped by posterior wall of urinary bladder; one segment of distal ileum above and sigmoid colon with sign of acute diverticulitis. but there is litter pus inside the cavity, lysis of the cavity and separate the sigmoid, small bowel. wash the abscess cavity with a lot of warm NS, no bubble nor dirty liquid come out from diverticulm even when squeezing the colon.
- #31 After operation 1 week , this patient presented fever with wound discharge, drainage was clear, the culture was Ecoli, CT show the pelvic abscess is eliminated,No focal fluid collection throughout the abdomen and pelvis, thus suspect wound infection change antibiotic with Meropenem according to antibiotic sensitivity test result. After 2 week antibiotic, no significant drainage liquid was seen, inflammatory markers downtrend, control CT was no significant found, the antibiotic was downgraded to Flagyl and ceftazidime, on 6/4 patient want to discharge.
- #32 Take home massage: CT scan is the glod standard as the initial imaging, diagnosis diverticilitis, it can assess the severity an presence of complication, according to Hinchey classification guide the treatment. Acute diverticulitis also can be conservative treatment with antibiotic. The surgery should be individualized, according to depends on hemodynamic stability, the degree of peritoneal contamination, acute organ failure, immunosupperssion, combidities,Endoscopy should be performed after resolution of an episode of acute complicated diverticulitis, rule out colon cancer and inflammatory bowel disease.
- #33 This folw chart is concluded the treatment of the acute diverticulitis