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General Surgery
Diverticular Disease and Colonic Volvulus
Built from Maingot's Abdominal Operations
What’s inside
15 sections · 180 slides
Overview
- Scope of this topic
- Terms used in diverticular disease
Diverticular Disease
What the pouches are, why they form, and how often they matter
- Colonic diverticula as a structural abnormality
- <10%
- Changing prevalence and hospital burden
- Early descriptions of colonic diverticula
- Recognition of diverticulitis and its complications
- Established knowledge by the early twentieth century
Why Diverticula Form
Diet, pressure, motility and the ageing bowel wall
- Diverticular disease as a disease of Western populations
- Fibre, intraluminal pressure and wall tension
- Protective factors
- Normal colonic motor patterns
- Evidence from intraluminal manometry
- Myoelectric changes in the colonic wall
- Geographic and ethnic variation
- Right-sided diverticular disease in Asian patients
Structure of the Diseased Colon
Where the pouches sit and what changes in the wall
- Colonic diverticula as false diverticula
- Muscle layers of the colonic wall
- Relationship of the diverticulum to the vasa recta
- Formation of a colonic diverticulum
- Cross section of a sigmoid colon containing diverticula
- Muscle changes described by Whiteway and Morson
- Elastosis and the concertina appearance
- Collagen composition and matrix metalloproteinase 1
- Resected sigmoid colon with diverticula
- Mucosal view of colonic diverticula
- Connective tissue disorders associated with diverticular disease
- Onset of diverticulitis by microperforation
- Progression from blocked diverticulum to peritonitis
Clinical Presentation
The acute attack, the indolent form, and what else it could be
- Frequency of symptoms in diverticulosis
- Features of an acute attack of diverticulitis
- Anatomical mimics of urinary infection and appendicitis
- Physical findings in acute diverticulitis
- Differential diagnosis of left iliac fossa pain
- Initial management of uncomplicated diverticulitis
- Indolent presentation of diverticular disease
- Left colonic diverticula on double-contrast barium enema
- Computed tomography of sigmoid diverticula
- Single sigmoid diverticulum on computed tomography
- Counselling and the limits of elective surgery for symptoms
Complications
Perforation, fistula, bleeding, obstruction and abscess
- Complications of diverticular disease
- Free perforation and feculent peritonitis
- Fistula formation in diverticular disease
- Sites of diverticular fistula
- Colovesical fistula
- Investigation of a suspected colovesical fistula
- Colocutaneous fistula
- Coloenteric and colovaginal fistula
- Diagnosis of colovaginal fistula
- Operative repair of diverticular fistula
- Diverticular haemorrhage
- Why a diverticulum bleeds
- Presentation of diverticular bleeding
- Localising the site of colonic bleeding
- Choice of test in acute lower gastrointestinal bleeding
- Radionuclide scanning and endoscopy in bleeding
- 5%
- Mesenteric angiogram of the sigmoid colon
- Contrast blush of active diverticular bleeding
- Investigation after bleeding has stopped
- Large bowel obstruction from diverticular disease
- Active diverticulitis occluding the colonic lumen
- Confirming obstruction and excluding malignancy
- Management of obstructing diverticular disease
- Diverticular abscess
- Detecting a diverticular abscess
- Treatment of a diverticular abscess
- Limits of percutaneous drainage and the role of laparoscopy
- Paracolic abscess with a percutaneous drainage tube
- Giant colonic diverticulum
- Presentation and treatment of giant colonic diverticulum
- Diverticular disease and colorectal cancer
Investigations
What imaging adds, and when it must be avoided
- Computed tomography in acute diverticular disease
- Water-soluble contrast studies
- Contrast extravasation into an abscess cavity
- Contrast enema in fistula and the danger of barium
- Role of ultrasound scanning
- Assessment of the colon after a first attack
- Additional tests for fistulous disease
Grading the Severity
The Hinchey classification and its modern subdivisions
- The Hinchey stages of diverticulitis
- Reading the Hinchey classification
- Modified Hinchey classification
- Purpose of the modified stages
Medical Management
Antibiotics, senior decisions, and a shift away from resection
- Antibiotic therapy for acute diverticulitis
- Deciding to operate
Elective Surgery
Who benefits, what the recurrence figures actually show
- Selecting patients for elective resection
- The two-attack rule and its origins
- Recurrence figures quoted for diverticulitis
- Evidence against routine prophylactic resection
- Nature of recurrent attacks
- Outcomes after elective resection
- Risk-reducing measures before elective surgery
- Diverticular disease in patients under 50 years
- The challenge to aggressive surgery in young patients
- Readmission and unnecessary operation in young patients
- Diverticular disease in immunocompromised patients
- Outcome of diverticulitis after immunosuppression
- Measures that may reduce recurrent attacks
The Acute Abdomen
Localised peritonitis, generalised peritonitis and the operative choices
- Acute diverticulitis with localised peritonitis
- Progress on conservative treatment
- Mortality in complicated diverticulitis
- Acute diverticulitis with generalised peritonitis
- Nonoperative management in the unfit patient
- Trial of resuscitation before operating
- Resection versus nonresection in feculent peritonitis
- Laparoscopic lavage in the emergency setting
- Extent of resection
- Deciding whether to anastomose in the acute setting
- Hartmann's procedure
- Risks of restoring bowel continuity
- Primary anastomosis in the emergency setting
- Hartmann's procedure compared with primary anastomosis
Laparoscopic Surgery
Where keyhole surgery has taken over, and what it costs
- Laparoscopic surgery in colorectal disease
- Laparoscopic exploration and drainage
- Laparoscopic colonic resection for diverticular disease
- Reported laparoscopic outcomes and publication bias
- US$3458
- Summary of diverticular disease
- Unresolved questions in diverticular disease
Colonic Volvulus
A loop of colon twisted on its own mesentery
- Definition of colonic volvulus
- Epidemiology of colonic volvulus
- Age and sex distribution
- Predisposing factors for colonic volvulus
- Anatomical basis of volvulus at different sites
- Closed-loop obstruction in colonic volvulus
- Caecal volvulus and caecal bascule
- Ileosigmoid knotting
- Clinical presentation of colonic volvulus
- Complications of colonic volvulus
- Plain radiography in colonic volvulus
- Plain film signs of sigmoid and caecal volvulus
- Sigmoid volvulus on plain supine abdominal radiograph
- Caecal volvulus with proximal small bowel obstruction
- Contrast enema and the bird beak sign
- Computed tomography in colonic volvulus
- Swirl sign of sigmoid volvulus on computed tomography
- Beaking at the site of sigmoid volvulus
- Beaking effect in caecal volvulus
- Endoscopy as a diagnostic and therapeutic tool
- Mortality of colonic volvulus
- Principles of management in colonic volvulus
- Endoscopic decompression of sigmoid volvulus
- Technique of endoscopic decompression
- Definitive surgery for recurrent sigmoid volvulus
- Nonresectional operations for sigmoid volvulus
- Options for the patient unfit for anaesthesia
- Laparoscopic options in sigmoid volvulus
- Management of caecal volvulus
- Outcomes of operations for caecal volvulus
- Cecostomy tube fixation of an untwisted caecal volvulus
- Sigmoid volvulus compared with caecal volvulus
- Conclusions on colonic volvulus
Takeaways
What to carry away from both conditions
- Key points on diverticular disease
- Key points on colonic volvulus
References
The source list for this topic
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- Maingot's Abdominal Operations, 12th Edition