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Diverticular Disease and
Hemorrhoids
Lance T. Uradomo, MD, MPH
Assistant Professor of Medicine
Division of Gastroenterology and Hepatology
University of Maryland School of Medicine
Director of Endoscopy, Baltimore VA Medical Center
Center for Cancer Surveillance and Control Teleconference
Maryland Department of Health & Mental Hygiene
January 21, 2009
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Outline
• Diverticular Disease
– Diverticulosis
– Diverticulitis
– Diverticular Hemorrhage
• Hemorrhoids
– Classification
– Therapy
2
Anatomy
Splenic Flexure
Hepatic Flexure
Descending
Transverse
Ascending
Sigmoid
Cecum
Rectum
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm
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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
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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
Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125
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Pathophysiology of Diverticula
• Associations with diets low in dietary fiber and
high in refined carbohydrates.
– Less bulky stools that retain less water and may alter
gastrointestinal transit time;
– Increase intracolonic pressure and make evacuation
of the colonic contents more difficult.
• Other factors:
– physical inactivity, constipation, obesity, smoking, and
treatment with nonsteroidal antiinflammatory drugs.
Jacobs DO, N Engl J Med 2007;357:2057-66
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Symptoms of Diverticulosis
• Most are asymptomatic
• Some experience crampy pain or
discomfort in the lower abdomen,
bloating, and constipation.
8
Acute Diverticulitis
• Most common complication of diverticular
disease
– 10-25% of patients
Martel J, Raskin J. J Clin Gastroenterol 2008; 42: 1125
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Pathophysiology of Diverticulitis
• Fecalith
• Bacterial flora
• Micro or macro
perforation
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm
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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
Thickening
Jacobs DO, N Engl J Med 2007;357:2057-66
Diverticulum
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Diagnostic Tests
• Colonoscopy and sigmoidoscopy are typically
avoided when acute diverticulitis is suspected
because of the risk of perforation.
• Recommended after approximately 6 weeks, to
rule out the presence of other diseases, such as
cancer and inflammatory bowel disease.
Jacobs DO, N Engl J Med 2007;357:2057-66
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Treatment of Uncomplicated
Acute Diverticulitis
• Antibiotics
Jacobs DO, N Engl J Med 2007;357:2057-66
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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
16
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
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Diverticular Hemorrhage
• Rupture of the vasa recta at the dome of
a diverticulum
Stone C. http://www.nlm.nih.gov/medlineplus/ency/presentations/100158_1.htm
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Diverticular Hemorrhage
• Source proximal to the splenic flexure in
60%
• Mean age 66 year old
• Most common cause of life threatening
lower GI bleed (3-5% of those with
diverticulosis)
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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.jpg
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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
Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82
Browder W. Ann Surg 1986 Nov;204(5):530-6
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Therapy for Diverticular
Hemorrhage
• Angiography
– No purge required
– Vasopressin infusion
• 91% stop bleeding, but 50%
rebleed on cessation of
vasopressin
• Transcatheter embolization is
more definitive, but is
associated with a up to 20%
risk of intestinal infarction.
Jensen DM et alN Engl J Med 2000 Jan 13;342(2):78-82
Browder W. Ann Surg 1986 Nov;204(5):530-6
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Surgery for Diverticular
Hemorrhage
• Frequency of surgery among patients with
severe or massive rectal bleeding from 24
to 78%.
– 18 – 25% of those requiring transfusions
• Persistent instability despite aggressive
resuscitation demands operative
intervention and is necessary
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
26
Surgery for Diverticular
Hemorrhage
• Surgical mortality is approximately 10%
• Exploratory laparotomy identifies a source
in 78 percent of patients without a
preoperative diagnosis
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
27
Surgery for Diverticular
Hemorrhage
• Segmental colectomy
– Source of bleeding has been localized
– Rebleeding in 0 to 14%
• Subtotal colectomy
– Patient continues to bleed without an identified site of
bleeding
– Morbidity 37%
– Mortality rates 11 – 33%
• Blind segmental resection is contraindicated
– Rebleeding rate 42%
– Morbidity 83%
– Mortality 57 %
Summarized in Young-Fadok T, et al. Colonic diverticular bleeding. Uptodate.com
28
Recurrence of Diverticular
Hemorrhage
•
•
•
•
1
2
3
4
year
year
year
year
9%
10%
19%
25%
Longstreth. Am J Gastroenterol 1997; 92: 419
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Hemorrhoids
Bleday R. Treatment of hemorrhoids. Uptodate.com
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Hemorrhoids
• Arise from a plexus of
dilated veins arising
from the superior and
inferior hemorrhoidal
veins.
• 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
• Painless bleeding usually associated with a bowel
movement.
• Bright red blood coats the stool at the end of defecation.
• Blood may drip into the toilet or stain toilet paper.
• Chronic blood losses from hemorrhages can be
substantial enough to induce iron deficiency anemia.
• Bleeding should be investigated:
– Flexible sigmoidoscopy or anoscopy in low-risk
younger patients
– Colonoscopy
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Pruritus
• Irritation or itching of perianal skin
• Some patients also complain of mild
incontinence or wetness.
34
Pain
• Thrombosis, which can occur in both internal and
external hemorrhoids. Thrombosis of external
hemorrhoids may be associated with excruciating
pain.
• Easily visible, purple, elliptical mass extending from
the anal to the perianal skin.
• Thrombosed internal hemorrhoids may also cause
pain, but to a lesser degree than external
hemorrhoids. An exception is when internal
hemorrhoids strangulate
35
Therapy:
American Society of Colon and Rectal
Surgeons (ASCRS) Guidelines
• Conservative (not generally effective in Grades III, IV)
– Fiber
• Meta-analysis of seven controlled trials found a significant
and consistent benefit from fiber supplementation in
improving bleeding (RR 0.50, 95% CI 0.28-0.68)
– Also potentially useful:
• Sitz baths
– help to relieve irritation and pruritus. In warm water two
to three times per day.
• Topicals
– Steroids
Alonso-Coello P, et al. Cochrane Database Syst Rev 2005;(4):CD004649.
36
Therapy
• 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
38
Therapy
• In patients with thrombosed external
hemorrhoids
– Either observation or excision. Excision within
48 to 72 hours of the onset of symptoms will
result in the most rapid relief of symptoms.
39
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
40
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
41
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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