Diverticular Disease and Hemorrhoids - texashealth.org

Diverticular Disease, Colonic
Polyps and Hemorrhoids

Raymond Staniunas MD FACS
Metroplex Colorectal Specialist
Texas Health Physician Group

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Outline

 Diverticular Disease

 Diverticulosis
 Diverticulitis

COLONIC POLYPS
Diagnosis, prevention and treatment

 Hemorrhoids

 Classification
 Therapy

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Anatomy

Hepatic Flexure Splenic Flexure
Descending
Transverse Sigmoid

Ascending Rectum
Cecum

Stone C. http://www.nlm.nih.gov/medlineplus/ency/presen3tations/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

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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/e5ncy/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 26008; 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;357:2057-766

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Symptoms of Diverticulosis

 Most are asymptomatic
 Some experience crampy pain or discomfort in the lower

abdomen, bloating, and constipation.

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Acute Diverticulitis

 Most common complication of diverticular disease

 10-25% of patients

Martel J, Raskin J. J Clin Gastroenterol 20098; 42: 1125

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Pathophysiology of Diverticulitis

 Fecalith
 Bacterial flora
 Micro or macro

perforation

Stone C. http://www.nlm.nih.gov/medlineplus/enc1y0/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 Diverticulum

 CT scan Thickening

Jacobs DO, N Engl J Med 2007;357:201527-66

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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;357:201357-66

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Treatment of Uncomplicated
Acute Diverticulitis

 Antibiotics

Jacobs DO, N Engl J Med 2007;357:2057-6164

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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

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Treatment of Complicated Diverticulitis

 IV antibiotics
 Bowel rest
 Analgesia
 Percutaneous drainage (CT-guided)
 Surgery

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Diverticulitis Surgery

 Emergency often requires colostomy
 Often can get patient to elective sigmoid resection
 Surgery utilizes minimal invasive laparoscopic

techniques with less pain and shorter hospital stay
 Davinci Robotics

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Anatomy

Hepatic Flexure Splenic Flexure
Descending
Transverse Sigmoid

Ascending Rectum
Cecum

Stone C. http://www.nlm.nih.gov/medlineplus/ency/prese1n9tations/100158_1.htm

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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 20

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Colonic polyps

 Benign growth(like a skin mole) growing on the
inside lining of the large intestine

 Some have the potential to grow into colon cancer
 Most are detected and removed by colonoscopy

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Colon polyps

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Colon polyps

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Colon polyps

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Colon polyps

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Colonic polyp prevention

 Polyps and cancer may form from exposure of the
lining of the intestine to toxins in fecal waste

 By increasing the transit time in the colon evacuation
with fiber supplementation the exposure to toxins is
decreased

 Screening colonoscopy at age 50 or ten years earlier
than family history of significant colorectal neoplasia
and possibly breast, ovarian, uterine cancer

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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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Hemorrhoid causes

 Varicose veins of the bottom
 Pressure from pregnancy
 Straining and constipation
 We all have them

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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.

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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.

 Must be suspicious for Anal Fissure as cause of
“hemorrhoidal 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

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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 230305;(4):CD004649.

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Therapy

 Minimally invasive

 Mostly for Internal Grades I, II, III.

 Band ligation
 Thermal coagulation

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Hemorrhoids

Bleday R. Treatment of hemorrhoids. Uptodate.com35

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Hemorrhoidal Ligation-banding

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Therapy

 Surgery

 For refractory to banding or significant external prolapse
 Thrombosed external
 THD and rectopexy procedure
 Standard excisional hemorrhoidectomy

 Complications following a standard closed hemorrhoidectomy
include urinary retention, urinary tract infection, fecal
impaction, delayed hemorrhage, and pain

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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.

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THD Hemorrhoid Surgery

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THD Hemorrhoid Surgery

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THD

 Much less pain than standard excisional
hemorrhoidectomy

 Less complications such as urinary retention
 Not good for very large external hemorrhoids

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Summary-Diverticulitis

 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-polyps

 Colonic polyps are benign growths that have the
potential to form cancer if they are the adenomatous
type.

 Screening colonoscopy to detect polyps is
recommended at age fifty or earlier if there is a
family history

 Polyps/colon cancer may be somewhat higher risk in
breast cancer and diabetes

 Adding fiber may help decrease polyp/cancer
formation

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Summary-Hemorrhoids

 Hemorrhoids are common and can cause bleeding,
itching, or pain (with thrombosis) or fissure

 Mild cases can be treated with fiber supplements and
topical medications.

 Most treated with in office banding
 Minimal post surgery pain techniques are available.
 Surgery is reserved for severe cases refractory to

banding or large external prolapse or thrombosis

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Questions?

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