Professional Documents
Culture Documents
Hemorrhoids
Diverticular Disease
Diverticulosis
Diverticulitis
Diverticular Hemorrhage
Hemorrhoids
Classification
Therapy
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Anatomy
Hepatic Splenic
Flexure Flexure
Descending
Transver
se
Ascendi Sigmoid
ng
Cecum
Rectum
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 3
Definitions
Diverticula an abnormal pouch or sac
opening from a hollow organ (as the colon
or bladder)
Diverticulosis - the presence of diverticula
in the colon
Diverticulitis - inflammation or infection of a
diverticulum of the colon
Diverticular Disease - a disorder
characterized by diverticulosis or
diverticulitis
2005 Merriam-Webster, Incorporated 4
Introduction
Diverticula
form at weak
points in the
bowel wall
Often where
vasa recta
vessels
penetrate the
muscle layer
Most common
in left colon
(70-90%)
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 5
Epidemiology
Prevalence of Diverticula
Age
< 10% in people under 40 year old
50% to 66% over age 80
Gender
Geography
Western countries
Low prevalence in Asia and Africa
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Acute Diverticulitis
Fecalith
Bacterial flora
Micro or
macro
perforation
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 10
Presentation of Acute
Diverticulitis
Symptoms
Left lower quadrant pain
Fever
Leukocytosis
Exam
Abdominal tenderness
Mass
High pitched bowel sounds
Rebound
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Diagnostic Tests
Xray Free air, perforation
CT scan
Diverticulu
Thickenin m
g
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Jacobs DO, N Engl J Med 2007;357:2057-66
Treatment of Uncomplicated
Acute Diverticulitis
Hospitalization
Inability to tolerate oral medications and
liquids
Comorbidities
Pain severe enough to require narcotic
analgesia
Symptoms fail to improve despite
adequate outpatient therapy
Complicated diverticulitis
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Complicated Diverticulitis
Abscess
Peritonitis
Obstruction
Fistula formation
Hemorrhage
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Treatment of Complicated
Diverticulitis
IV antibiotics
Bowel rest
Analgesia
Percutaneous drainage (CT-guided)
Surgery
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Recurrent Diverticulitis
25% will have more than one attack of acute
diverticulitis
Parks et al 1969
Recurrence was more virulent and lead to
recommendation for elective resection after the
second episode in >50year old and after first
episode in younger patients.
More recent data fails to show worse prognosis in
recurrent attacks.
American Society of Colon and Rectal Surgeons:
Decision for elective resection is on a case by
case basis
Sheth et al Am J Gastroenterol 2008; 103: 1550 18
Diverticular Hemorrhage
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm 19
Diverticular Hemorrhage
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Diverticular Hemorrhage
Diagnosis
History and Physical Exam
Painless, sometimes mild cramps
Hematochezia (red blood per rectum)
Radionucleotide Imaging
Technetium sulfur colloid. Scans are
obtained shortly after intravenous injection,
looking for evidence of extravasation. 0.1
mL/min
Sensitivity 97%, specificity 83%, and
positive predictive value 94%
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Diverticular Hemorrhage
Diagnosis
Colonoscopy
Polyethylene glycol for colon purge
preparation
Sedation
May be therapeutic
http://www.uptodate.com/online/content/images/gast_pix/Bleeding_diverticulum_Endos 22
.jpg
Diverticular Hemorrhage
Diagnosis
Angiography
Performed by Interventional Radiologist
Bleeding at a rate on 0.5 1mL / min
May be therapeutic
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Therapy for Diverticular
Hemorrhage
Spontaneous resolution in
90%
Colonoscopy: Study found
0% versus 53% rebleeding
in colonoscopy vs.
medical treatment
Epinepherine
Cautery
Clips
Submucosal layer in
the lower rectum
External or internal:
below or above the
dentate line.
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Classification
Grade I: May bulge into the lumen but do
not extend below the dentate line.
Grade II: Prolapse out of the anal canal with
defecation or with straining but reduce
spontaneously.
Grade III: Prolapse out of the anal canal with
defecation or straining, and require the
patient to reduce them into their normal
position.
Grade IV: Irreducible and may strangulate.
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Bleeding
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Pruritus
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Pain
Thrombosis, which can occur in both internal
and external hemorrhoids. Thrombosis of
external hemorrhoids may be associated with
excruciating pain.
Minimally invasive
Mostly for Internal Grades I, II, III.
Band ligation
Coagulation
Sclerotherapy
Cryotherapy
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Therapy
Surgery
For refractory to above
Thrombosed external
Complications following a standard closed
hemorrhoidectomy include urinary retention,
urinary tract infection, fecal impaction,
delayed hemorrhage, and pain
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Therapy
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Summary
Diverticular Disease
Diverticulosis is common and usually
asymptomatic.
Symptoms range from mild cramping and bowel
movement changes to life threatening infection or
hemorrhage
Diverticulitis is an infection of an diverticulum
Uncomplicated cases can be treatment with
outpatient oral antibiotics
Severe or complicated cases may require
hospitalization and invasive therapeutic
modalities
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Summary
Diverticular Bleeding
Is a common cause of massive lower GI
hemorrhage
Colonoscopy and angiography may be
diagnostic and therapeutic
Surgery is reserved for uncontrolled or
refractory cases with best outcomes when
the site of bleeding has been localized
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Summary
Hemorrhoids are common and can
cause bleeding, itching, or pain (with
thrombosis)
Mild cases can be treated with fiber
supplements and topical medications.
Minimally invasive (endoscopic)
techniques are available.
Surgery is reserved for severe cases or
thrombosis
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Questions?
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