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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