Large Intestines: Diverticulitis

by Kevin Pei, MD

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    00:01 Welcome back. Thank you for joining me on this discussion of diverticulitis in the section of general surgery.

    00:10 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.

    00:41 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.

    01:24 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.

    02:44 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.

    03:13 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.

    03:27 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.

    04:05 Hinchey classification three is generalized purulent peritonitis. Four is fecal contamination.

    About the Lecture

    The lecture Large Intestines: Diverticulitis by Kevin Pei, MD is from the course General Surgery.

    Included Quiz Questions

    1. Diverticulitis can be asymptomatic.
    2. Diverticulitis is inflammation and infection of diverticula.
    3. Low fiber diet can predispose to diverticulitis.
    4. Diverticulosis is left sided predominant.
    5. Diverticulitis always has microperforation.
    1. ...low intraluminal pressure.
    2. ...low fiber diet.
    3. ...constipation.
    4. ...obesity.
    5. ...adhesions.
    1. Perforation.
    2. Microperforation.
    3. Enteritis.
    4. Recurrent diverticulitis.
    5. Small bowel obstruction.
    1. Class 3 --- Diverticulitis with pericolic abscess.
    2. Class 1 --- Diverticulitis with phlegmon formation.
    3. Class 2 --- Diverticulitis with wall off pelvic abscess.
    4. Class 3 --- Diverticulitis with generalized purulent peritonitis.
    5. Class 4 --- Diverticulitis with generalized fecal peritonitis (fecal contamination).

    Author of lecture Large Intestines: Diverticulitis

     Kevin Pei, MD

    Kevin Pei, MD

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