Colonic Diverticula

Colonic Diverticula are hollow outpouching common structural abnormalities of colon. 
In the western world, approximately 75% diverticula are found in the left colon mostly in the sigmoid but can also present the whole colon. Whereas the right side diverticular diseases are more common in Southeast Asia.

Classification

A. Congenital:- Here all 3 coats of the bowel are included in the wall of the diverticulum . For example; Meckel’s diverticulum.
B. Acquired:- Here muscular layer absent in the diverticulum for example ; sigmoid diverticular diseases.

Etiology of  Colonic Diverticula

Deficiency in dietary fibers, altered collagen structure with aging, mortality disorder & rising intraluminal pressure because of the narrow sigmoid colon. These diseases mostly rare in African and Asian countries because of their dites are high in natural fibers.

 Diverticular disease (complications )

Most people are asymptomatic but somehow 10-30% may experience symptomatic complications such as follows:- 
• Diverticulitis.
• Perforation that leads mostly to pericolic abscess formation in somehow also leads to generalized peritonitis as well.
• Intestinal obstruction.
• colonic hemorrhage occurs due to erosion of vessels that are adjacent to a diverticulum.
• Formation of fistula (approximately 5%) such as, colovesical, enterocolic & colovaginal colocutaneous and colovesical fistula mostly seen.

Clinical manifestations of Colonic Diverticula

In Mild case, symptoms like distension , flatulence & sensation of heaviness in lower abdomen. These features assumed that due to result from mixing of raised luminal pressure that affecting wall tension and Increased viseral hypersensitivity. Surgery is rarely done.
In the case of diverticulitis, there is persistent lower abdominal pain and tenderness mostly in left iliac fossa sometimes also in right iliac fossa if sigmoid loop location across the midline and may be accompanied with diarrhea or constipation.
Tender and thickened sigmoid colon when palpation is done. Tenderness is also present if abscess is formed in the rectum.

Generalized tenderness abdomen after perforation.
Painless and profuse hemorrhage from colonic diverticula. If in case of bleeding from sigmoid colon will be bright red with clots, whereas bleeding from right side colon is darker. If bleeding persists or reoccurring nature then transfusion and finally resection is needed.
Fever 
Stool mixed with blood and mucus sometimes.
Colovesical fistula results in recurrent UTI & pneumonia or even stool in the urine.
After Hysterectomy colovaginal fistula more common.
Rarely diverticular diseases perforate into the retroperitoneum that leads to a psoas abscess and also may form fistulation.

 Classification of complicated Diverticulitis by Hinchey:- 
Grade 1:- Mesenteric or pericolic abscess.

Grade 2:- Pelvic abscess.

Grade3:- Purulent peritonitis.

Grade4:- Faecal peritonitis.

Investigation or Diagnosis of Colonic Diverticula

• Medical as well as family history.
• Blood test 
• plain radiographs can demonstrate a pneumoperitoneum .
• Spiral CT as it has excellent sensitivity and specificity for finding bowel wall thickness, abscess formation, and extraluminal diseases as well as an assignment of complicated diverticular diseases.
• Contrast studies and endoscopy usually not done in the acute case because might causes perforation.
• CT can demonstrate a fistula.
• Colonoscopy to look for any diverticula or signs of diverticulitis
• Biopsy in order to exclude tumors.

Management of Colonic Diverticula

• Highly recommend taking fiber-rich diet and bulk-forming laxatives.
• Antispasmodics in case of recurrence pain.
• Acute diverticulitis I’d treated with IV antibiotics that cover gram-negative bacilli as well as anarobes along with appropriate resuscitation and pain analgesic.
• NPO (Nil Per Oral ) and catheterization done .
• As soon as possible CT is done in order to conform diagnosis and to assess the complications.
• After remission of acute attack investigation of the bowel is done by endoscopy, barium enema or CT virtual colonoscopy.
• Percutaneous drainage in case of pericolic abscess.

Surgical management for diverticular diseases

The main goal of the emergency operation is to manage the peritoneal infection.
Indications:  • Generalized peritonitis. • Not responding well with medical treatment.
Approach
# Laparotomy is done but before starting it proper attention is needed as in acute case laparotomy for diverticular disease mortality risk is 15% whereas 50% in case of fecal peritonitis.
Hartmann’s procedure ( oversewn rectal stump and left iliac fossa colostomy)and resection with colonic washout and anastomosis. 

The majority of emergency operation for perforated diverticular diseases are Hartmann’s procedures.
Elective surgery is usually done by considering complications that arise from disease conditions. By resection of affected bowel diverticular fistula can be cured. Bleeding from diverticular disease is usually responds to conservative management and occasionally requires resection.

Angiography and on table lavage and colonoscopy required to localized bleeding site. And if can’t localized bleeding site then go for subtotal colectomy and ileostomy.

In elective setting surgery can be done laparascopic but it’s challenging.

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