Relief from Diverticular Disease

Managing Diverticular Disease

Managing Diverticular Disease

Stop The Pain. Manage Your Diverticular Disease And Live A Pain Free Life. No Pain, No Fear, Full Control Normal Life Again. Diverticular Disease can stop you from doing all the things you love. Seeing friends, playing with the kids... even trying to watch your favorite television shows.

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New Diverticulitis Breakthrough Ebook Summary

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Author: Mark Anastasi
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Outcomes After Laparoscopic Colectomy for Diverticular Disease

The incidence of diverticulosis of the colon increases gradually with age so that by the eighth decade of life almost 80 of the elderly have some diverticula of the colon. Only a minority of these patients complain about acute or chronic diverticulitis and are candidates for surgery. The indications for emergent surgery are well established Acute abdomen with perforation and diffuse peritonitis. A more conservative approach may be chosen in patients with acute diverticulitis and local peritonitis or abscess. Most surgeons try to treat the inflammatory process first using antibiotics and computed tomography scan-guided percutaneous drainage of abscess, followed by elective resection with colorectal anastomosis if there is more than one episode, or if the first episode is complicated by abscess. Emergent surgery is indicated only if the clinical situation does not improve under proper treatment with antibiotics and bowel rest either in the hospital or as an outpatient, depending on the...

Brian Scott Campbell and Samuel E Wilson

Intraabdominal infections are becoming more common in the geriatric patient, which is the fastest-growing segment of the population in North America. Due to varied and sometimes masked manifestations of illnesses in this population, the diagnosis of an intraabdominal infection may be challenging. The causes and incidence of intraabdominal infections are different in older patients when compared with younger patients. In older adults cholecystitis, diverticulitis, and intestinal obstruction, perforation, and ischemia are more common (see Table 1). Different or atypical presentations of these disorders may lead to delays in the diagnosis of abdominal complaints in elderly patients. Lack of fevers and leukocytosis are common in older patients with intraabdominal infections (1). Furthermore, mental confusion or dementia, as well as coexisting illnesses, may confound and complicate the history and physical examination. Despite these difficulties the diagnosis of intraabdominal infections...

Clinical Features of Infections

Infections in the elderly often present in an atypical, nonclassical fashion. Furthermore, the differential diagnosis of infectious diseases in the elderly differs from the young because it is dependent on both the clinical setting and the patient's underlying functional status. For example, free living, independent, healthy elderly are prone to respiratory infections, such as bacterial pneumonia, genitourinary infections and intraabdominal infections including cholecystitis, diverticulitis, appendicitis, and intraabdominal abscesses. Institution-bound elderly are more likely to develop aspiration pneumonia, urinary tract infection, (especially if a chronic indwelling bladder catheter is present), and skin and soft-tissue infections. Infections in the elderly differ from the young also because infections in this age group are often caused by a more diverse group of pathogens compared with the young. This is best exemplified by urinary tract infection, which in the young occurs almost...

Indications for Surgery

To obstruction, intra-abdominal abscesses, internal fistulae and less frequently due to chronic increasing anaemia or bleeding from digestive tract 24 . When the descending or sigmoid colon is affected, symptoms are similar to diverticulitis with the subsequent obstruction and pericolonic abscess. Indications for elective surgery may also include stenosis after failure of endoscopic dilatation, persistent diarrhoea resistant to conservative treatment and bleeding 25 . According to the course of the disease indications for the operation can be divided into urgent and elective. Indications for emergency surgery

Contraindications Precautions And Interactions

The glucocorticoids are administered with caution to patients with renal or hepatic disease, hypothyroidism, ulcerative colitis, diverticulitis, peptic ulcer disease, inflammatory bowel disease, hypertension, osteoporosis, convulsive disorders, or diabetes. The glucocorticoids

Entero Urinary Fistula EUF

Entero Vaginal Fistula

Other urological investigations like cystograms and excretory urograms are only occasionally useful. Small-bowel follow through, barium enema and colonoscopy are suggested because, even if the fistula is rarely demonstrated, they help to determine the extent and nature of the underlying disease and to exclude other causes of EUF such as diverticular disease or colonic malignancies 59,67, 74, 75 .

Gastrointestinal Tract Infection

Inguinal Colostomy

Diverticula are small pouches in the wall of the intestine, most commonly in the colon. If these pouches are present in large number the condition is termed diverticulosis, which has been attributed to a diet low in fiber. Collection of waste and bacteria in these sacs leads to diverticulitis, which is accompanied by pain and sometimes bleeding. Diverticula can be seen by radiographic studies of the lower GI tract using barium as a contrast medium, a so-called barium enema (Fig. 12-9). Although there is no cure, diverticulitis is treated with diet, stool softeners, and drugs to reduce motility (antispasmodics). DIVERTICULITIS

Infections In The Solid Organ Transplant Recipient

In the period of > 6 mo following transplant, three clinical groups with characteristic infectious complications are seen. Approximately 60-75 of patients require minimal immunosuppression and have good graft function by this time. In these patients, common infections such as respiratory tract infections, diverticulitis, and cholecystitis may occur. However, these infections may present in an atypical manner or have more serious sequelae due to the chronic immunosuppression. From 10 to 15 of patients will have chronic recrudescent viral infections, which may lead to end-organ damage. Etiologies include papovavirus (BK, JC), which may cause urethral stricture and hemorrhagic cystitis hepatitis B or C, which may result in subacute or chronic hepatitis Epstein-Barr virus, a causative agent of post-transplant lymphoproliferative disorders CMV, which most commonly manifests as retinitis at this time adenovirus and VZV. The remaining 10-20 of patients have poor allograft function and are...

Patterns of presentation

A sudden onset of severe abdominal pain which progresses rapidly, becomes generalised in site and constant in nature, in a' previously asymptomatic patient, suggests either perforation of a hollow viscus, a ruptured aortic aneurysm or a mesenteric arterial occlusion. Prior symptoms may help the differential diagnosis preceding constipation suggests colonic carcinoma or diverticular disease as the catisc of the perforation, and preceding dyspepsia suggests a perforated peptic ulcer. Coexisting peripheral vascular disease, hypertension, cardiac failure or atrial fibrillation suggest a vascular disorder, e.g. aortic aneurysm, mesenteric ischaemia. The development of peripheral circulatory failure (shock) following the onset of the pain, strongly suggests intra-abdominal bleeding, e.g. ruptured aortic aneurysm or ectopic pregnancy. The rapid onset of abdominal pain may also occur if an organ twists - A slower onset and progression of abdominal pain over hours or days...

Acquired Iron Deficiency

Organs responsible for development of iron-deficiency anaemia are the uterus (increased menstrual blood loss, pregnancy), the oesophagus (varicose veins in patients with liver cirrhosis), the stomach and bulbus duodeni (hiatus hernia, aspirin and detrimental effects of other non-steroidal antiinflammatory drugs, peptic ulcer, carcinoma, partial gastrectomy), the small intestine (hookworm, coeliac disease, diverticulosis, morbus Crohn, angiodysplasia), the colon and rectum (carcinoma, diverticulosis, angiodysplasia, varices, colitis) and, rarely, the kidney and lung. Increased demands for iron, not met by adequate iron intake, occur in premature infants, during any period associated with increased growth, and during pregnancy. Poor diet is also a cause of iron deficiency in some socioeconomic groups in developed countries. Female blood donors in particular may develop iron deficiency. Self-inflicted blood loss is a diagnosis that should be considered if no cause can be found for severe...

Colonoscopy

Minate colitis, and at least 10 of patients who present with an IBD is regarded as having indeterminate colitis 22 . Usually, they are treated and monitored as are patients with UC unless signs of Crohn's disease develop. Other diseases that may resemble Crohn's disease are functional disorders (e.g. irritable bowel syndrome), immunomediated (e.g. connective tissue diseases), drug induced (e.g. nonsteroidal anti-inflammatory drugs (NSAID) , vascular (e.g. intestinal ischaemia), neoplastic (e.g. carcinoma, lymphoma), infective or diverticular disease.

Indications

An ileocolectomy is most frequently indicated in patients with benign disease, i.e., Crohn's disease, cecal diverticulitis, intestinal tuberculosis, enteric Behcet's disease, submucosal tumors (lipoma, gastrointestinal stromal tumor, lymphoma, carcinoid, etc.), giant villous adenoma and polyps, located in the ileocecal regions. Indications are rare for performing a limited ileocecal resection for malignancies of the terminal ileum, the appendix, or the cecum. This may be the procedure of choice in palliative resection for cecal cancer.

Editors Comments

Cannula positioning We agree that the use of multiple (up to six) can-nulae matters little with the final outcome of the patient compared with the use of three or four cannulae. Thus, a proper exposure is the key to an excellent operation and not the final number of cannu-lae, especially if the extra ones are 5 mm. Technique We would consider that, especially in a distal sigmoid cancer or diverticular disease, it is important to mobilize the proximal rectum, and to carefully identify and preserve the hypogastric nerves. This is readily accomplished using the magnification afforded by the laparoscope, and careful dissection coupled with it. An alternative to the suprapubic incision may be an extension of the left lower quadrant cannula incision for extraction of the specimen. Alternatively, if the specimen is large or adherent to surrounding structures (diverticular disease), it may be useful to consider a hand-assisted approach, using a suprapubic Pfannenstiel incision of 7-8 cm (see...

Rectal bleeding

The cause of this important symptom should always be determined. Though frequently due to haemorrhoids or an anal fissure, these are so commonplace that their presence in a patient with rectal bleeding should not lead to the assumption of cause and effect. The differential diagnosis includes colorectal carcinoma, ulcerative colitis, infective colitis and complicated diverticular disease (Table 5.17). Bleeding from the anal canal is bright red it is usually clearly separate from the faeces and often seen only on the toilet paper. 1 laemorrhoidal bleeding may be profuse and splash the toilet bowl and or continue following defecation. Bleeding from an anal fissure is usually associated wilh

Methods

The MEDLINE database via PUBMED was searched for English literature published since 1991. The MeSh terms diverticulitis and laparoscopic* were used for the search. All 240 abstracts of the discovered The overall quality of the studies is level 3-5. There are no randomized controlled trials (RCTs) that compared both approaches in patients with diverticulitis. This is somewhat surprising because in some countries diverticular disease is the most common indication for laparoscopic sigmoid resection. In theory, it should be easy to set up some RCTs from experienced centers. One small study compared whether the anastomosis should be accomplished after closure of the laparotomy and

Discussion

Elective laparoscopic colectomy for diverticular disease is at least as safe as conventional surgery because 1) Morbidity seemed to be lower, and 2) mortality is at least the same. Whether there is a shorter period of postoperative ileus or whether patients experience less pain are also questionable because of a lack of quality of comparative data. The described shorter periods of ileus and postoperative pain in noncom-parative case series are not supportive data favoring laparoscopic over conventional surgery and may only suggest that early feeding accelerates postoperative recovery. Some surgeons may point to the results of RCTs on colorectal cancer (see Chapter 11.5) to support their belief about the superiority of the laparoscopic approach. However, surgery for diverticulitis differs in many aspects from oncologic surgery. Regarding the role of the laparoscopic technique in emergent situations, i.e., in patients with acute diverticulitis with perforation or abscess, some surgeons...

Haemorrhage

Life-threatening haemorrhage and exsanguination from Crohn's disease in four patients were described in 1995, when 34 cases similar to the medical literature were reviewed 45 . Five patients died, in 30 (90 ) surgery was necessary to cease haemorrhage and ileocolectomy was the most frequently performed procedure. Mesenteric arteriography was positive in 17 patients, providing precise preopera-tive localisation, resulting in no mortality in this group 45 . A retrospective study of 34 patients with acute lower gastrointestinal bleeding in Crohn's disease, the largest to date, shows a more favourable result 46 . Acute haemorrhage was defined as acute rectal bleeding originating in diseased bowel, requiring a transfusion of at least 2 units of red blood cells within 24 h. Upper gastrointestinal tract haemorrhage or anal lesions and postoperative bleeding were excluded. Recently, several promising studies have been published that describe transcatheter embolization for the treatment of...

IBD and its Mimics

Drugs, especially non-steroidal anti-inflammatory drugs (NSAIDs), have also been known to cause colitis, the features of which can be confused with IBD, and the elderly seem to be at a higher risk 102 . Thus a drug history is mandatory when investigating patients with suspected IBD. Non-steroidal anti-inflammatory drugs (NSAIDs) can cause small-intestinal ulceration together with mucosal inflammation and colonic ulcerations. Other drugs such as methyl-dopa and gold treatment can also be complicated by colitis 103-106 . Colitis associated with diverticular disease of the sigmoid is a well-recognised feature and can be mistaken for features of IBD. Mucosal biopsies from an area of inflammation associated with diverticular disease may show features of crypt distortion, basal plasmacytosis, cryptitis and even crypt abscesses 107 . CD-like changes in the sigmoid of a patient with diverticular disease are an idiosyncratic inflammatory response to the diverticulosis rather than to coexistent...

Results

Diverticulitis Laparoscopic Surgery

The indications for elective resection were mainly acute diverticulitis or chronic diverticulitis with stenosis, with only occasional patients having fistula to the bladder. The conversion rate ranged from 4 to 26 , the operative time 120-240 min, the time to tolerate regular diet 1-21 days, the length of hospital stay 2-55 days, the morbidity 0 -23.7 , and the mortality 0 -3 (Table 11.3.1). Retrospective chart review on all patients operated on because of diverticulitis. Figure 11.3.1. Morbidity risk ratio (RR) including the 95 CI after laparoscopic and conventional surgery for diverticulitis. Figure 11.3.1. Morbidity risk ratio (RR) including the 95 CI after laparoscopic and conventional surgery for diverticulitis. Figure 11.3.2. Wound infections risk ratio (RR) including the 95 CI after laparoscopic and conventional surgery for diverticulitis. Figure 11.3.2. Wound infections risk ratio (RR) including the 95 CI after laparoscopic and conventional surgery for diverticulitis. Figure...