WHY DISCUSS DIV.ITIS ?hospital admissions 2006-2009

(NL)

•In the USA from 1998 to 2005 a 26 % increase in div-itis (mostly in18-44 year old group).

•A diverticulum is an pouching out of the mucosa of the gut through the muscularis externa

•the diverticula are in fact pseudo-diverticula.

•Meckels diverticulum is a true diverticulum

prevalence diverticula

40 year 5 %

60 year 30%

85 year 65 %

Causes of diverticula

•low fibre diet

•to little mobility

•to little fluid in diet

•smoking

•obesitas (BMI> 22.5 !)

inflammation of a diverticulum

•local changes of wall; hypertrofy (?)

•local neurological changes ( lower motility+higher pressure) (?)

•impaction of faeces in diverticulum -->necrosis of wall --> translocation of bacteria--> inflammation

uncomplicated Diverticulitis

investigation•history (comorbidity, immune

depressed, medication) ( no vomiting !)

•physical examination (temperature > 38.5C pain,tenderness, peritonitis?)

•total blood( leucocytosis) and CRP >50 mg/L

•this together gives an accurate diagnosis in 40 - 65 %

In 75 % of the patients there is no diagnosis

possible without imaging.

more investigation ?

•ultrasound ?

•CT scan ?

•endoscopy ??

•MRI??

Ultrasound of diverticulitis

sensitivity and specificity of US is 90 %

if US is inconclusive then CT

CT scan

sens. and specificity of CT is 95 and 99% resp

advantage of CT over US is that other diagnosis

can be made when there is no diverticulitis

MRI ? expensive and time consuming

sens. and spec. 85 and 100 % resp.

no X rays

How to treat uncomplicated diverticulitis?

treat the pain

mild laxans

(antibiotics only when infiltrates outside colon)

no hospitalization

no bedrest

no diet measures necessary

uncomplicated means 0 and Ia in Hinchey

score

so: no suspicion of an abces, peritonitis,

perforation or bleeding

chances for recidive after first episode

10 % chance in the first year and every year 3 %

(> 50 year)

total chance for recidive aprox 25 %

complicated diverticulitis

Hinchey 1b, 11, 111,1V

5- 10 % of patients < 40 year

50- 80 % of complicated div-itis at first presentation

start very quickly with IV antibioticsdrainage of abces > 5 cm ( CT or US guided

with needle or drain)

Hinchey 111 and 1V always operationbleeding :ENDOSCOPY with intervention or

embolisation(CT-angio) when profuse or when failure with

scope + units of blood of course when necessary

operation Hinchey 111 and 1V

• deviating stoma• Hartmann procedure

• resection with primary anastomosis• laparoscopic lavage with drainage of

abdominal cavity

deviating stoma

Hartman procedure

resection with primary anastomosis

Laparoscopic lavage with drainage

for today the end

thank for your attention