Diverticulosis, Volvulus & Rectal Prolapse

Dr.B.Selvaraj MS;Mch; FICS;

Professor of SurgeryMelaka Manipal Medical collegeMelaka 75150 Malaysia

A . General principles l . Colonic diverticula are mucosal outpouchings through the

submucosa and the muscular layer of the colon.2 . They occur most commonly in the sigmoid colon, and in

10% of patients, they involve the entire colon.3. They arise between antimesenteric taenia and the

mesenteric taenia at the site of entry of the blood vessels

DIVERTICULOSIS

B . Epidemiology and etiology l . Diverticular disease of the colon is an acquired condition.2 . This condition is a disorder of modern civilization and is

associated with consumption of refined food products . It is rare in rural African and Asian populations where dietary fiber is high.

DIVERTICULOSIS

DIVERTICULOSIS

C. Clinical features : Most patients are asymptomatic. Occasionally, diverticulosis is associated with lower abdominal colicky pain.

D. Diagnosis of diverticular disease l . A history of chronic intermittent lower abdominal pain and

presence of diverticula on barium enema or colonoscopy are indicative of this condition.

2. In acute diverticulitis , CT may help distinguish a phlegmon from an abscess.

3 . Sigmoidoscopy and colonoscopy should be avoided in acute flare-ups of the disease because the risk of perforation is high.

DIVERTICULOSIS

DIVERTICULOSIS

DIVERTICULOSISSaw tooth appearance

E. Management l . In acute diverticulitis/phlegmon, intravenous (IV) fluids,

antibiotics, and bowel rest are necessary.2. Abscesses should be drained, usually percutaneously

under CT guidance.3. Fecal peritonitis necessitates exploratory laparotomy. The

most commonly performed operation is the Hartmann procedure, in which the sigmoid colon is resected, the proximal colon is exteriorized as a stoma, and the rectal stump is oversewn.

DIVERTICULOSIS

E. Management4. Patients who develop strictures may need an elective

sigmoid colectomy and primary anastomosis .5 . Fistulae are a complex problem. The patient's nutrition

should be optimized, and infection should be controlled before surgical repair or resection is attempted

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F. Complications l . Acute diverticulitis : A diverticulum may become inflamed

when a fecalith obstructs its neck. Patients present with left lower quadrant abdominal pain, fever, and leukocytosis.

2. Diverticular abscess: Acute diverticulitis may result in a peridiverticular abscess. Patients experience severe pain, high fever, and white bloodcell (WBC) elevation . A CT scan can identify the collection and guide percutaneous drainage.

3 . Diverticular phlegmon: The local response to the diverticular inflammation may lead to formation of an inflammatory mass or phlegmon. Such patients need bowel rest and IV antibiotics .

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F. Complications 4.Diverticular stricture: Recurrent episodes of inflammation

may lead to fibrosis ,resulting in luminal narrowing. Patients may present with acute large bowel obstruction.

5.Fecal peritonitis:Perforation of diverticula may lead to fecal peritonitis ,which has a mortality rate of about 50% . Patients need emergency exploratory laparotomy

6. Hemorrhage: Erosion of a peridiverticular vessel can lead to significant bleeding.

7. Fistula: Peridiverticular abscess may erode into adjacent viscera, forming a fistula

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Hinchey Classification of Complicated Diverticulitis

• Hinchey 1-pericolic or mesenteric abscess• Hinchey 2-contained pelvic abscess• Hinchey 3-generalized purulent peritonitis• Hinchey 4-generalized feculent peritonitis

DIVERTICULOSIS

A . General principles l . In volvulus, the bowel twists on its own mesenteric axis ,

leading to bowel obstruction. 2 . Venous congestion may lead to bowel infarction

VOLVULUS

B. Sigmoid volvulus l . Epidemiology and etiology a. Sigmoid volvulus accounts for about 5% of all cases of

large bowel obstruction in developed countries. The incidence is higher in the Third World, which has been attributed to fiber-rich diets.

b. The narrow mesenteric base of the sigmoid colon, along with an elongated floppy loop, makes it particularly susceptible to twisting on its axis .

c. This condition is seen mostly in elderly, institutionalized patients with chronic medical and neuropsychiatric conditions .

d. It is postulated that psychotropic drugs affect colonic motility, thus predisposing to volvulus .

VOLVULUS

VOLVULUS

B. Sigmoid volvulus 2. Clinical features a. Patients present with colicky abdominal pain, constipation,

nausea, vomiting, and an inability to pass flatus. b . The air is able to enter the sigmoid loop but unable to exit.

This leads to progressive distention of the sigmoid loop. c. The abdomen is usually markedly distended and tympanic

on percussion. Severe pain with peritoneal signs is an indicator of underlying bowel ischemia and/or impending perforation

VOLVULUS

3. Diagnosis a. In most patients , the diagnosis can be made on the

combination of history, physical examination, and plain abdominal radiography.

b. The rectal vault is usually empty on examination. c. Plain radiographs show a markedly distended sigmoid loop,

which assumes a bent inner tube or inverted U-shaped appearance, with the limbs of the sigmoid loop directed toward the pelvis

d. Single-contrast barium enema examination is useful because it demonstrates that the barium readily enters the empty rectum and usually encounters a stenosis, likened to a beak, the so-called bird beak or bird-of-prey sign.

VOLVULUS

VOLVULUSCoffee bean appearance

Bird’s beak appearance

4. Management a. Patients may be dehydrated and should be fluid resuscitated. b. Early decompression via rigid proctoscopy, flexible

sigmoidoscopy,or colonoscopy should be attempted. This will allow the mucosa to be visualized for signs of ischemia. The instrument may pass into the obstructed segment. If this maneuver succeeds, there is a sudden, dramatic gush of fluid and feces. It is recommended that a well-lubricated rectal tube be used to prevent early relapse and facilitate continued drainage.

c. A full colonoscopy should be performed after bowel preparation to rule out an associated neoplasm.

VOLVULUS

4. Management d . Volvulus can recur in up to 50% of patients ; therefore,

elective sigmoid resection should be offered to all good-risk surgical patients .

e. Occasionally, it is not possible to decompress the bowel endoscopically.Alternatively, proctoscopy may reveal mucosal ischemia suggesting sigmoid necrosis . Such a patient should be emergently taken to the operating room.

VOLVULUS

A . Epidemiology and etiology l . Procidentia is an uncommon condition in which the full

thickness of the rectal wall turns inside out into or through the anal canal. The extruded rectum is seen as concentric rings of mucosa . The cause is poorly understood, and the disorder is a form of intussusception. Most patients have a history of straining with intractable constipation or chronic diarrhea. There is a high incidence in patients with mental retardation. Patients have impaired resting and voluntary sphincter activity and impaired continence.

2 . Predominates in females with a female:male ratio of 5 : 1 to 6 : 1

RECTAL PROLAPSE

RECTAL PROLAPSE

A . Epidemiology and etiology 3 . Classification a. Partial: prolapse of rectal mucosa only b. Complete : First degree with an occult prolapse : Several

anatomic defects are constantly demonstrated in patients with chronic rectal prolapse.

c. Complete : second-degree ; prolapse to , but not through, the anus

d. Complete : third-degree; protrusion through the anus for a variable distance

RECTAL PROLAPSE

RECTAL PROLAPSE

B. Clinical features: Early symptoms include anorectal discomfort during defecation. Feeling of incomplete evacuation is common. In overt prolapse ,

protrusion occurs only during or after defecation. As the problem becomes more pronounced, the prolapse may be precipitated by coughing, walking, and exertion. Bleeding from ulcerated mucosa.

C . Diagnosis: Demonstrated on clinical exam by asking the patient to strain or

in the bathroom asking the patient to defecate. Occult prolapse by defecography.

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D . Management: l . The goal is to repair the prolapse and prevent intussusception

from recurring. 2. The most reliable repair is via the abdomen involving anterior

resection with rectopexy.- Ripstein’s operation 3. For elderly or unfit patients , a transperineal

rectosigmoidectomy is more appropriate . 4. Incontinence is due to mechanical stretch of the sphincter as

well as pudendal nerve dysfunction. 50% of patients improve after repair.

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RECTAL PROLAPSE

RECTAL PROLAPSE

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