Elsevier

Current Problems in Surgery

Volume 47, Issue 9, September 2010, Pages 680-735
Current Problems in Surgery

New Paradigms in the Management of Diverticular Disease

https://doi.org/10.1067/j.cpsurg.2010.04.005Get rights and content

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Historical Perspective

Diverticula were first reported by Littre in the 1700s. These were felt to be pathologic curiosities and unlikely to cause symptoms.2 Fleischman first used the term “divertikel” in 1815.3 In 1849, Cruvehiler described small herniations of the mucosa through the muscle layer of the sigmoid colon.4 A diagnosis of diverticulitis was considered so rare that it was not even mentioned in British surgical textbooks in the early part of the 20th century. With the increase in the use of contrast

Incidence

Diverticulosis is one of the most common colonic conditions in Western populations. Since the 20th century, an increasing prevalence of diverticular disease has been noted, particularly in industrialized nations. Diverticulosis is rare under the age of 30. Thereafter, the incidence of the diverticulosis is such that more than 40% develop diverticula by the age of 60 years and more than 60% of those aged 80 years or older are affected.10, 11

The exact incidence of diverticulosis is difficult to

Pathologic Features

Most colonic diverticula are considered pulsion or false diverticula. They contain only the mucosa and muscularis mucosa and not all layers of the bowel wall as a true diverticulum does. Diverticula appear macroscopically as saccular outpouchings of the colon and are generally small in size, ranging from 0.5 to 1.0 cm. They are acquired over time, in part, because of increased intraluminal pressures. Diverticula typically penetrate through the colonic wall in areas of relative weakness where

Pathophysiologic Features

The pathophysiology of the development of diverticulitis has focused on the structural abnormalities of the colon wall (termed a tenia specific elastosis), disordered motility and generation of high intracolonic pressures (segmentation), and the role of dietary fiber.

Clinical Manifestations of Diverticular Disease

There are 3 main clinical presentations of diverticular disease (Table 1). The most common clinical presentation of diverticulitis is left-sided abdominal pain with or without an associated mass, fever, and leukocytosis. Patients generally resolve the acute episode after treatment with antibiotics. Another manifestation is smoldering disease that only partially improves with antibiotics and medical therapy. Such patients have recurrent symptoms that can manifest with ongoing low grade fever and

Laboratory and Diagnostic Imaging

Most patients with acute diverticulitis have an elevated white blood cell count. Patients with a colovesical fistula may have an abnormal urinalysis and/or culture. Polymicrobial urine cultures are common.

Although several different modalities have been used to evaluate patients with suspected diverticular disease, CT has emerged as the study of choice. Flat and upright plain films of the abdomen are commonly obtained in the evaluation of the patient with acute abdominal pain to exclude

Complicated Diverticular Disease

Complicated diverticulitis generally refers to diverticulitis associated with perforation, fistula, abscess, stricture, or obstruction. Diverticular bleeding is associated with diverticulosis and not diverticulitis. In an effort to be able to compare different groups of patients with perforation/abscess, the Hinchey classification has been used and is divided into stages I to IV.145 Stage I is diverticulitis associated with pericolic abscess; stage II is a more distant abscess such as a pelvic

Elective Management

Open sigmoid resection is generally performed through a midline incision. Preoperative mechanical bowel preparation is not necessary but is often performed.175 Preoperative intravenous antibiotics are administered. The sigmoid colon is mobilized and proximal and distal points selected for resection. The proximal resection margin should be in soft pliable bowel and it is not necessary to resect all proximal diverticula. The distal resection margin is the proximal rectum since anastomosis to the

Recurrent Diverticulitis

Recurrent diverticulitis following resection is uncommon. In the patient presenting with abdominal pain following resection for diverticulitis, a systematic evaluation should be performed to exclude other causes of pain. Etiologies such as inflammatory bowel disease, ischemic colitis, colorectal cancer, adhesive disease, gynecologic pathology, and irritable bowel syndrome should be considered. Patients with diverticular disease have significant overlap with irritable bowel syndrome. Additional

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