Tic Talk. Slide 1. Slide 4. Slide 2. Slide 5. Slide 3. Slide 6. Tics in the Colon. Beyond the Basics November 3, Vocabulary.

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1 Slide 1 Slide 4 Tic Talk Tics in the Colon Beyond the Basics November 3, 2012 Diverticulosis Nancy Schlossberg, RN, CGRN Susan Mitchell, RN, CGRN Slide 2 Objectives Slide 5 Vocabulary Discuss the difference between diverticulosis and diverticulitis and methods of treatment of these diseases. Discuss other areas in the GI tract where diverticula may be found. Diverticulum: Sac-like protrusion / herniation of mucosa & submucosa through weak points in muscular colonic wall Typically 5-10mm Slide 3 Presentation Slide 6 Vocabulary Tics in the colon Tics in other areas Diverticulosis: presence diverticula w/o inflammation Diverticular disease: symptomatic diverticula Diverticulitis: inflammation & infection of diverticula Schwartz s Principles of Surgery (2005)

2 Slide 7 Incidence & Prevalence Among most prevalent conditions in Western & industrialized society First noticed: early 1900 s - processed foods Among leading reasons OP visits & hospitalization Approximately 130,000 U.S. hospitalizations / year Danny O. Jacobs, M.D., M.P.H., Diverticulitis, N Engl J Med 2007; 357: , November 15, Slide 10 Incidence & Prevalence By sex Age <50 Ages Age >70: By age Age 40 < 5% Age 60 30% Age 85 >65% More common in males Slight prevalence in women More common in women <age % of cases, more frequently in males Obesity major risk factor Usually sigmoid and / or descending colon tics Slide 8 Incidence & Prevalence Slide 11 Classifications Most common in resource-rich countries Lower prevalence in Western vegetarians consuming high fiber diet Congenital / True Diverticulum Typically proximal colon Pouch contains all colon layers U.S.: Left-sided diverticula predominate Asians, including Asian Americans: right-sided diverticula predominate Rural Africa & Asia: almost unknown Acquired / Pseudo / False Diverticulum Typically distal colon, mainly sigmoid Pouch contains only mucosa & submucosa covered by serosa Minh Chau, T Nguyen, Chief Editor: Julian Katz, Diverticulitis, emedicine.medscape.com/article/ overviewupdated: Sep 22, 2011 Pulsion (pushing) Slide 9 Incidence & Prevalence Slide 12 Physiology 5-10%: full colon involvement Arteries penetrate muscularis to reach submucosa & mucosa 5%: Saint s Triad Occurrence of HH, diverticulosis & cholelithiasis Local hernias develop in weak regions of the colon where vasa recta (blood vessels) penetrate circular muscle

3 Slide 13 Pathophysiology Slide 16 Uncomplicated Sigmoid colon small diameter results in highest pressure zone Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers Segmentation increased intraluminal pressure mucosal herniation Significant minority of patients complain IBS like symptoms: Cramping, bloating, constipation alternating with diarrhea, mild to severe LLQ pain, heartburn, no relation to food, feeling distention relieved by passing flatus, rectal bleeding unrelated CRC Recent studies demonstrate motility abnormalities in patients with symptomatic uncomplicated diverticulosis High fiber may prevent diverticula by creating a larger diameter colon & less vigorous segmentation Low fiber diets distend the colon less than high fiber diets Therap Adv Gastroenterol November; 4(6): doi: / X Slide 14 Risk Factors Association with lifestyle Prospective observational studies Physical activity & high-fiber diet associated with lower risk than low-fiber, highly refined carb diets Case-control studies Non-steroidal anti-inflammatory drugs, corticosteroids, opiate analgesics associated w/ perforated diverticular disease Calcium antagonists have protective effect Japan, Singapore, Thailand develop diverticula affecting mainly right colon Humes, David, Smith J, Spiller, Robin, Clinical Evidence Handbook: Colonic Diverticular Disease, Am Fam Physician Nov 15;84(10): Slide 17 Conservative Treatment High fiber diet Keeps stool soft Lowers intraconlonic pressure Returns electrical activity to normal Increases fecal mass Decreases transit time Slide 15 Types Slide 18 Conservative Treatment Simple: 75% No complications Considered asymptomatic Typically incidental colonoscopy finding Complicated: 25% Abscesses, fistula, obstruction, peritonitis, sepsis A.N.D recommends grams daily* Added fruit, vegetables Bran supplement, Probiotic yogurt Polyethylene glycol, Fluid Non-opiod pain medication (constipation) Exercise WGO Practice Guidelines Diverticular Disease, World Gastroenterology Organisation, 2007 Academy of Nutrition and Dietetics (A.N.D.) in 2012

4 Slide 21 Evidence Large, prospective study of men w/o known diverticular disease, nut, corn, popcorn consumption did not increase risk of diverticulosis or diverticular complications Jama. 2008; 300(8): Slide 19 Patient Teaching Written resources Facility, homegrown, including sample diets National Institute of Diabetes, Digestive and Kidney Diseases(NIDDK) ases /pubs/diverticulosis/index.aspx Emphasize fluid Follow PCP instructions Recommended CRC screening Slide 22 Take Away Reconsider recommendation to avoid these foods Low-Residue Diet in Diverticular Disease: Putting an End to a Myth Nutr Clin Pract. 2011;26(2): Diverticulitis: something new under the sun? Arch Surg. 2011;146(3):324. Cyclical Increase in Diverticulitis During the Summer Months Arch Surg. 2011;146(3): Nuts and Corn and Diverticulitis JWatch Gastroenterology. 2009;2009(130):5. All you need to read in the other general journals BMJ. 2008;337(sep02_1):a1510. Let Them Eat Nuts (and Popcorn)! Neither Causes Diverticular Complications JWatch General. 2008;2008(828):2. Slide 20 Myth? Nut, corn, & popcorn consumption increase the incidence of diverticular disease? Slide 23 Myth? Should we treat uncomplicated symptomatic diverticular disease with fiber?

5 Slide 24 Evidence Slide 27 Take Away While low intake of fibre is associated epidemiologically with an increased risk of developing diverticulosis, the recommendations for fibre as a treatment are based on weak evidence that is old, largely observational, and uncontrolled (BMJ 2011; 342 doi: /bmj.d2951 (Published 25 May 2011) Cite this as: BMJ 2011;342) Study offers valuable insights on diverticulosis risk factors. More research needed before MDs change dietary recommendations. Better understanding why asymptomatic diverticula form can potentially reduce population at risk for symptomatic disease. Peery AF, et al A high-fiber diet does not protect against asymptomatic diverticulosis Gastroenterology 2012;DOI: /j.gstro Slide 25 Evidence Lack of evidence for fiber in symptomatic diverticular disease. Increasing fiber may relieve constipation, but may also increase flatulence & aggravate pain in some people. For patients who already take a lot of fiber it may be worth reducing fiber intake. However, as obesity has been linked to increased risk of symptoms of diverticular disease, a diet containing more fiber is often of lower energy density & may aid weight loss and improve symptoms. (BMJ 2011; 342 doi: /bmj.d2951 (Published 25 May 2011) Cite this as: BMJ 2011;342) Slide 28 Myth? Diverticulosis Increased adenoma rate? Slide 26 Evidence Slide 29 Evidence UNC researchers found that consuming a diet high in fiber raised the risk of developing diverticulosis. Findings counter common belief that constipation increases a person s risk of diverticulosis. Colonic diverticulosis was associated with increased adenoma detection rate in patients undergoing first-time screening colonoscopy. A biological reason for this association seems implausible. Peery AF, et al A high-fiber diet does not protect against asymptomatic diverticulosis Gastroenterology 2012;DOI: /j.gstro Gastrointestinal Endoscopy, Volume 73, Issue 4, Supplement, pp AB212-AB213, April 2011

6 Slide 30 Take Away Slide 33 Diverticulitis Possibly, presence of diverticulosis prompts endoscopist to conduct a more careful exam, although the scope withdrawal times measured in this study did not support this presumption. Large prospective study needed to confirm findings. Gastrointestinal Endoscopy, Volume 73, Issue 4, Supplement, pp AB212-AB213, April Diverticulitis is the swelling (inflammation) of an abnormal pouch (diverticulum) in the intestinal wall. These pouches are most often found in the large intestine (colon). The presence of the pouches themselves is called diverticulosis. Slide 31 Take Away Slide 34 Risk Factors Use your expertise during colonoscopy. With all colorectal diseases, preventative care & early detection are the best way to avoid further complications. Aging Low dietary fiber Physical inactivity Gender Slide 32 Slide 35 Risk Factors Tics in the Colon Obesity gaining recognition as a possible contributing factor in diverticulitis. Diverticulitis Men with body mass index (BMI) of 30 were 78% more likely to develop diverticulitis than men with a body mass index (BMI) less than 21.

7 Slide 36 Risk Factors Men who gained more than 45 pounds since age 21 had a higher risk of diverticulitis. And there was a positive association between diverticulitis and waist size. Slide 39 Simple / Uncomplicated In this form of diverticulitis the perforation is immediately walled off so that an abscess does not form and peritonitis (inflammation of the peritoneal wall of the inner abdomen) does not occur. Slide 37 Symptoms Slide 40 Simple / Uncomplicated 10-25% of people who have diverticulosis will develop diverticulitis. Most common symptom is abdominal pain. May be mild and get progressively worse; usually is severe and sudden. Will exhibit LLQ tenderness on exam. May experience nausea, vomiting, fever, pain, chills, change of bowel habits. Usually requires: Bed rest, Bowel rest, NPO, Oral antibiotics, Possible pain medication, and Liquid diet for a short time. Slide 38 Uncomplicated vs. Complicated Slide 41 Complicated Diverticulitis occurs when one or more diverticula develops a microscopic or macroscopic (visible) perforation. This starts an inflammatory reaction in the bowel wall and surrounding tissue. The perforation can then progress in one of two directions - either simple or complicated. The first potential is for the development of simple (or uncomplicated) diverticulitis. The other direction a micro- or macroperforation of colon diverticula may take is to develop into complicated diverticulitis. Complicated diverticulitis is more critical and presents with additional symptoms depending on the complexity of the condition.

8 Slide 42 Recurrent Diverticulitis Slide 45 Diverticulitis Risk Factors: Age < 50 years (younger patient) Presence of one or more comorbid conditions History of one or more previous episodes of acute diverticulitis Complicated diverticulitis almost always requires surgery. Uncomplicated diverticulitis usually responds to medical therapy alone. The surgical options in complicated diverticulitis range from a minor procedure involving the placement of a drain, to a more serious procedure involving open incision and exploration of the abdomen. Slide 43 Diagnosis Slide 46 Diverticulitis Thorough history & physical Complete blood cell count, urinalysis, & flat & upright abdominal radiography CT, water-soluble contrast enema, cystography, endoscopy, & ultrasound may be performed Investigation continues in several areas Possible link between diverticular disease & inflammatory bowel disease Management of diverticular disease Use of probiotics in the prevention & treatment of diverticular disease Indications for surgery for uncomplicated diverticulitis Slide 44 Complications Abscess Fistula Obstruction from scarring Bleeding Perforation Peritonitis Medical emergency that requires immediate care Sepsis perforation Slide 47 Summary Diverticulitis: the swelling (inflammation) of an abnormal pouch (diverticulum) in the intestinal wall. Risk factors: include age, low dietary fiber, physical inactivity & gender. Uncomplicated or Complicated Treatment focus: Clearing up the inflammation & the infection Resting the colon Preventing or minimizing complications Surgical intervention may be needed.

9 Slide 48 Slide 51 Meckel s Diverticulum Tics in Other Areas Include in differential diagnosis of patient with abdominal complaints, regardless of age Symptoms include: Melena, rebound tenderness, and right lower-quadrant pain, bleeding Symptoms resemble other GI conditions (e.g. appendicitis, colonic diverticulitis. Diagnosis by technetium 99m pertechnetate scan Slide 49 Small Bowel Diverticula Slide 52 Meckel s Diverticulum Believed to develop as result of abnormalities in peristalsis, intestinal dyskinesis, & high segmental intraluminal pressures. Generally asymptomatic, except for Meckel s. Symptoms reflect complications Most common: nonspecific epigastric pain or bloating sensation Some studies note a peak in complications from (e.g. bleeding & perforation/obstruction) in 4th & 5th decades of life. Some experts suggest surgery of incidentally found Meckel s in males under 40 or those at higher risk of complications associated with clinical factors, such as the presence of ectopic mucosa or attached by a fibrous connection. Slide 50 Meckel s Diverticulum Slide 53 Jejunal Diverticula True diverticulum (all layers) Most common congenital anomaly Location: antimesenteric border in the ileum Remnant of duct (omphalomesenteric) that connected fetal midgut & yolksac Rule of 2 s applies Excluding Meckel s, small bowel diverticula &/or diverticulitis are most prominent in the proximal jejunum Associated with small intestine motility disorders Most commonly observed in age years Slightly more common in males Reported incidence of less than 0.5% on upper GI films & 0.3 to 1.3% on autopsy

10 Slide 54 Jejunal Diverticululitis Slide 57 Duodenal Diverticula Presents as a focal inflammatory mass involving the proximal small bowel. Presenting symptoms: Epigastric pain, fever, nausea, and vomiting associated with elevated white blood cells Complications Rare Typically managed without surgery May include Diverticulitis Perforation with peritonitis Bowel obstruction Biliary obstruction Bleeding Slide 55 Jejunal Diverticulitis May show on CT scan as an inflamed loop Early intervention is crucial to prevent perforation and sepsis Laparotomy or laparoscopy with resection and side-to-side anastomosis remains the best management Slide 58 Gastric Diverticular Disease Typically 1-3 cm in size Up to 75% form near GE junction Usually on lesser curvature or posterior gastric wall May simulate a left adrenal mass If on the posterior wall, can herniate through an area of dorsal mesentery & fuse with left body wall Slide 56 Duodenal Diverticula Slide 59 Esophageal Diverticulum Approximately 5 x more common than other small bowel diverticula Found in all areas of duodenum Thought to be acquired/pulsion but are also congenital 50 % associated with colon diverticulosis Normally asymptomatic but may present with Non-specific pain in the upper abdomen or umbilical area Pain which is made worse by eating Pain relieved by vomiting, belching, or changing position True: all layers False: only the mucosa Intramural: occurring within the wall Three locations for esophageal diverticulum 1. Paryngeal/cricoidal 2. Mid-esophageal or midpoint 3. Epiphrenic

11 Slide 60 Zenker s Diverticulum Slide 63 Zenker s Diverticulum Pharyngeal out pouching readily seen in the cervical region immediately above UES Diagnosis Barium swallow Endoscopy risks perforating diverticulum Complications May fill with food/liquid & lead to dysphagia &/or aspiration Aspiration pneumonia most common Bleeding & perforation May interfere with proper intake Slide 61 Zenker s Diverticulum Slide 64 Zenker s Diverticulum Abnormality in the function of the upper esophageal sphincter muscle (cricopharyngeus) False, pulsion pharyngeal diverticulum Typically found in older females Treatment No treatment necessary if small & asymptomatic Larger, symptomatic cases traditionally treated by neck surgery to resect the diverticulum & incise cricopharyngeal muscle Slide 62 Zenker s Diverticulum Slide 65 Take Away Symptoms Aspiration, halitosis, throat gurgling Substernal chest pain Appearance of a mass in the neck Hoarseness, & weight loss can occur in advanced disease Blind pouch can be mistaken for esophageal lumen resulting in perforation Requires gentle scope insertion!

12 Slide 66 Epiphrenic Diverticula < 10% all esophageal diverticula Majority asymptomatic, incidentally found on radiographic examinations Lateral esophageal wall, distal 3 to 4 cm esophagus False diverticulum (mucosa & serosa only) Pulsion diverticulum (high intraluminal pressures) Often associated with HH, achalasia Slide 69 Midthroacic / Epiphrenic Diverticula Symptoms Dysphagia Regurgitation Aspiration Retrosternal chest pain Heartburn Complications Re: underlying esophageal motility disorders Esophageal obstruction Bezoar formation Cardiac dysrhythmia Bleeding (life-threatening) Development carcinoma within the pouch (rare, serious) Slide 67 Epiphrenic Diverticula Patient with reflux esophagitis & peptic stricture GI Motility online (May 2006) doi: /gimo29 Slide 70 Midthroacic / Epiphrenic Diverticula Asymptomatic: No treatment Symptomatic Treat underlying typically spastic, esophageal motility disorder or stricture Surgical repair may include Esophageal myotomy Fundoplication to prevent reflux Surgical mortality reported 9% for epiphrenic diverticula Slide 68 Midesophageal / Midthoracic Diverticula Response to pull from fibrous adhesions (traction) following lymph node infection, usually TB or fungal Form from increased intraluminal pressure True diverticulum (all layers) Associated with motility abnormalities (achalasia and diffuse esophageal spasms) Usually asymptomatic, discovered during routine radiographic exams Slide 71 Questions???

13 Slide 72 Final Take Away Diverticulum Congenital or acquired True or false Pulsion or traction Located throughout GI tract Usually asymptomatic Mild symptoms treated medically Moderate to severe symptoms / complications may require hospitalization & surgery Slide 73 References Strate LL, Lui YL, Aldoori WH, et al. Obesity increases the risk of diverticulitis and diverticular bleeding. Gastroenterology. 2009; `36: Comparing complicated and uncomplicated diverticulitis - by Nicole Evans M.D. Helium Rashaan Ali-Jones, MD, Management of complicated sigmoid diverticulitis, MSSURG.net, June 21, 2004 H. Nalil Aydin, Feza Remzi,Colinic diverticular disease, Cleveland Clinic Center for Continuing Education Disease Management Project, Jciech Staszewicz, Michel Christodoulou, Stefania Proietti, and Nicolas Demartines, Acute ulcerative jejunal diverticulitis: Case report of an uncommon entity, World Journal of Gastroenterology, October 28, Andeweg C, Peters J, Bleichrodt R, van Goor H. Incidence and risk factors of recurrence after sugery for pathology-proven diveticular disease. World Journal of Surgery, 2008 Jul;32(7):