Welcome back. Thank you for joining me on this discussion of diverticulitis in the section of general surgery.
Diverticulosis is a very common disease. It’s anatomically a herniation of mucosa to the wall of
the colon via areas of inherent weakness called the vasa recta where the vessels are coming into
the intestines. It can lead to secondary infection and microperforation which is then diagnosed
as diverticulitis. Itis meaning inflammation of the osis, so diverticulosis can progress to diverticulitis.
It’s typically associated with low fiber, constipation, and obesity, what we call sometimes
a Western diagnosis. There appears statistically a left colon predominance, we think largely
due to high intraluminal pressures as a result of the solid stools heading to the left side of
the colon. What are some physical findings of diverticulosis? Well, it’s interesting because
diverticulosis unlike diverticulitis may be very much asymptomatic. One of the classic presentations
of diverticulosis however is bleeding. Bleeding is not necessarily for a certain finding in diverticulosis.
But when you have lower GI bleeding, one of the things to keep on the top of your differential
diagnosis is diverticulosis. When diverticulosis gets infected secondarily and leads to microperforation,
we then have a situation of diverticulitis like I previously mentioned. Well, what are some
of the classic findings of diverticulitis once the diverticulosis has either been secondarily
infected or progressed to microperforation? Well, typically the patient presents with some
form of abdominal pain, whether this be in the left lower quadrant of the abdomen, if it’s likely
due to a sigmoid diverticulitis in the suprapubic region where sometimes patients often report
the sensation of incomplete voiding. Remember that the sigmoid colon is very floppy. It can either
be on the right side of the abdomen or down the left side of the abdomen. So, right sided,
lower quadrant abdominal pain can also be either due to right sided diverticulitis or because
you have a floppy sigmoid colon. But classically, it’s been described as left lower quadrant
abdominal pain. This pain can become generalized with perforation, although by definition,
diverticulitis is a microperforation. The perforation where we’re talking about generalized peritonitis
is usually associated with a large perforation. Oftentimes, patients also present with diarrhea.
This is likely a local inflammatory response. What laboratory findings will you find?
Well, in a routine chemistry, maybe everything is pretty much normal. On a CBC, you may see
increased white blood cell count or leukocytosis. Again, no specific lab finding is absolutely indicative
of diverticulitis. An index of suspicion is very important. Here, you’ll see a CT abdomen/pelvis.
The green arrow points to a collection. Notice that around the collection, it’s a ring-enhancing
collection with both fluid and air level. This is consistent with a pericolonic abscess.
You’ll also notice that if you follow the sigmoid colon, you’ll notice little pockets of air along the lining
of the colon indicative of diverticulitis and microperforation specifically. We have a standard
classification for describing diverticulitis based on radiographic findings. It’s called the
Hinchey classification. Let’s familiarize you with Hinchey classification. Hinchey classification
one is a phlegmon or pericolic abscess. If a walled-off abscess develops in the abdomen or
the pelvis, it becomes a Hinchey classification two. This is very similar to the CT scan that you just saw.
Hinchey classification three is generalized purulent peritonitis. Four is fecal contamination.