early colonoscopy in patients with acute diverticulitis ...early colonoscopy in patients with acute...

Early Colonoscopy in Patients with Early Colonoscopy in Patients with Acute Acute DiverticulitisDiverticulitis

Simon Bar-Meir, M.D..

Professor of MedicineProfessor of MedicineGermanisGermanis Kaufman Chair of Gastroenterology Kaufman Chair of Gastroenterology

Director, Dept. of Gastroenterology Director, Dept. of Gastroenterology ChaimChaim Sheba Medical Center, TelSheba Medical Center, Tel--HashomerHashomer

and and SacklerSackler School of Medicine, Tel Aviv UniversitySchool of Medicine, Tel Aviv University

Acute Acute DiverticulitisDiverticulitis

•• Clinical presentationClinical presentation•• CT scanCT scan

No No pericolicpericolic airair PericolicPericolic airair

Acute Acute DiverticulitisDiverticulitis

Differentiating from colonic carcinomaDifferentiating from colonic carcinoma

DiverticulitisDiverticulitis vs. Carcinoma on CTvs. Carcinoma on CT

•• DiverticulitisDiverticulitis::-- colonic wall thickeningcolonic wall thickening

•• Cancer:Cancer:-- colonic wall thickeningcolonic wall thickening

•• Overlap existsOverlap exists

-- pericolicpericolic fat infiltrationfat infiltration-- absence of absence of pericolicpericolic lymph nodeslymph nodes

-- adjacent lymph nodesadjacent lymph nodes-- intraintra--luminal massluminal mass

Colonoscopy in Acute Colonoscopy in Acute DiverticulitisDiverticulitis

•• Colonoscopy is recommended Colonoscopy is recommended •• But is postponed for 6 weeksBut is postponed for 6 weeks•• DiverticulitisDiverticulitis affects mostly the elderly affects mostly the elderly •• Elderly pts may be lost for followElderly pts may be lost for follow--upup•• Pts rePts re--admitted because obstructionadmitted because obstruction•• At surgery: colonic carcinomaAt surgery: colonic carcinoma


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Colonoscopy in Colonoscopy in DiverticularDiverticular DiseaseDisease

PenfoldPenfold JC. JC. PeforationPeforation of the colon of the colon

complicating colonoscopy: report of a case. complicating colonoscopy: report of a case.

DisDis Colon Rectum 1975; 18: 626Colon Rectum 1975; 18: 626--627627

Colonoscopy in Colonoscopy in DiverticularDiverticular DiseaseDisease

•• 42 42 y/oy/o female with rectal bleedingfemale with rectal bleeding•• Colonoscopy: multiple Colonoscopy: multiple diverticulidiverticuli•• At At splenicsplenic flexure flexure ““the movable tip the movable tip

mechanism broke downmechanism broke down””•• Abdominal distention and vomiting Abdominal distention and vomiting •• Admitted next day and died Admitted next day and died •• PM: 0.5 cm perforated PM: 0.5 cm perforated diverticulumdiverticulum

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitisis not advocatedis not advocated


•• DiverticulitisDiverticulitis is a sealed perforation is a sealed perforation

•• Occasionally evolves into free perforationOccasionally evolves into free perforation

•• Colonoscopy is postponed for 6 weeksColonoscopy is postponed for 6 weeks

•• Avoid the conversion into a free perforationAvoid the conversion into a free perforation

•• This policy is not evidenceThis policy is not evidence--basedbased


•• Experience?Experience?

•• Risk for perforation?Risk for perforation?

•• Any benefit?Any benefit?

AimAim

To evaluate the feasibility and safety To evaluate the feasibility and safety

of early colonoscopyof early colonoscopy

in patients with acute in patients with acute diverticulitisdiverticulitis

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitis-- 3 steps3 steps--

Colonoscopy in all patients with acute Colonoscopy in all patients with acute

diverticulitisdiverticulitis::

a) but no a) but no pericolicpericolic airairb) including b) including pericolicpericolic airairc) early vs. delayed c) early vs. delayed –– a controlled triala controlled trial

Feasibility studiesFeasibility studies

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitis-- 3 steps3 steps--




Patients and MethodsPatients and MethodsStep IStep I

•• Patients hospitalized for acute Patients hospitalized for acute diverticulitisdiverticulitis: :

-- LLQ abdominal tendernessLLQ abdominal tenderness-- feverfever--↑↑ WBCWBC

•• Diagnosis confirmed by abdominal CTDiagnosis confirmed by abdominal CT-- localized thickening of colonic walllocalized thickening of colonic wall-- Inflammation of Inflammation of pericolicpericolic fatfat

Patients and MethodsPatients and MethodsStep IStep I

Excluded:Excluded:

-- patients with:patients with:pericolicpericolic airairfree perforationfree perforation

-- previous colonoscopy within a yearprevious colonoscopy within a year

Patients and MethodsPatients and Methods•• Treated with IV antibioticsTreated with IV antibiotics

•• Signed a consent form Signed a consent form

•• Cleansing with oral Cleansing with oral phosphosodaphosphosoda

•• Colonoscopy on the day of dischargeColonoscopy on the day of discharge

•• Conscious sedationConscious sedation

•• Remained for at least 6 hrsRemained for at least 6 hrs

Telephone contact 1&3 days laterTelephone contact 1&3 days later

Flow Chart of PatientsFlow Chart of PatientsStep IStep I

49 pts agreed to colonoscopy

39 pts underwent colonoscopyno complications

10 pts excluded dueto pericolic air

6 pts excluded4 refused colonoscopy

2 had recent colonoscopy

55 pts with acute diverticulitis

Patients and MethodsPatients and MethodsStep IIStep II

•• Included:Included:

-- patients with patients with pericolicpericolic airair

•• Excluded:Excluded:

-- patients with free perforationpatients with free perforation

-- previous colonoscopy within a year previous colonoscopy within a year

Flow Chart of PatientsFlow Chart of PatientsStep IIStep II

67 pts with acute diverticulitis

58 pts agreed to colonoscopy

54 pts underwent colonoscopy6 had pericolic air

1/6 perforated

9 pts excluded7 refused colonoscopy

2 had recent colonoscopy

4 excluded due tofree perforation

Combined analysis of Combined analysis of the two studiesthe two studies

ResultsResults•• I07 pts consented colonoscopy I07 pts consented colonoscopy

•• 93 pts underwent colonoscopy 93 pts underwent colonoscopy

•• Age: 62 (38Age: 62 (38--85) yrs85) yrs

•• Gender (M/F): 47/60Gender (M/F): 47/60

•• No. of attacks:No. of attacks:-- 1: 91 pts (85%)1: 91 pts (85%)

-- 2: 16 pts (15%)2: 16 pts (15%)

•• Time to colonoscopy: 5.8 (3Time to colonoscopy: 5.8 (3--12) days12) days

Results•• CecalCecal intubationintubation: 75 pts (81%): 75 pts (81%)

•• Incomplete colonoscopy: 18 pts (19%)Incomplete colonoscopy: 18 pts (19%)-- 10 colonic stricture10 colonic stricture-- 5 pain 5 pain -- 2 poor preparation2 poor preparation-- 1 obstructing carcinoma1 obstructing carcinoma

•• Second colonoscopy:Second colonoscopy:-- success rate: 16 pts (100%)success rate: 16 pts (100%)-- 2 pts operated: carcinoma ; recurrent 2 pts operated: carcinoma ; recurrent diverticulitisdiverticulitis

Endoscopic Findings

•• Polyps: 11 in 9 patientsPolyps: 11 in 9 patientsSize: 10Size: 10--20 mm20 mmLocation:Location:-- 2 rectum2 rectum-- 4 descending colon4 descending colon-- 5 ascending colon5 ascending colon

•• Obstructing carcinoma of sigmoid colonObstructing carcinoma of sigmoid colon•• Chicken bone trapped in a Chicken bone trapped in a diverticulumdiverticulum

HistologyHistology

HistologicHistologic FindingsFindings

9 tubular adenoma 9 tubular adenoma

1 1 tubulovilloustubulovillous adenomaadenoma

1 1 tubulovilloustubulovillous adenoma with carcinomaadenoma with carcinoma

Endoscopic Findings



History of Pt with CarcinomaHistory of Pt with Carcinoma

•• 55 55 y/oy/o manman•• Clinical presentation of acute Clinical presentation of acute diverticulitisdiverticulitis•• Improved on antibiotic therapyImproved on antibiotic therapy•• Scheduled for colonoscopy 6 wks laterScheduled for colonoscopy 6 wks later•• Failed to show upFailed to show up•• Readmitted 2 Readmitted 2 mosmos laterlater•• Enrolled into the studyEnrolled into the study•• Underwent colonoscopyUnderwent colonoscopy•• Obstructing carcinoma at 50 cmObstructing carcinoma at 50 cm

Endoscopic Findings



Endoscopic Findings

•• 73 73 y/oy/o femalefemale•• Acute Acute diverticulitisdiverticulitis•• No improvement for 10 daysNo improvement for 10 days•• Underwent colonoscopy Underwent colonoscopy •• Chicken bone trapped in a Chicken bone trapped in a diverticulumdiverticulum•• Purulent discharge Purulent discharge •• Bone removed Bone removed endoscopicallyendoscopically•• Immediate improvementImmediate improvement

Bone Stuck in a Diverticulum

Complications

•• One patient perforated the sigmoid colonOne patient perforated the sigmoid colon•• An 88 y/o female with An 88 y/o female with pericolicpericolic air air •• Colonoscopy on day 9 of hospitalizationColonoscopy on day 9 of hospitalization•• She did well following surgeryShe did well following surgery•• Discharged 2 weeks laterDischarged 2 weeks later

SummarySummary

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitis::

-- Feasible, although more difficultFeasible, although more difficult

-- Safe, if exclude pts with Safe, if exclude pts with periperi--diverticulardiverticular airair

-- Therapeutic, in some pts with a refractory courseTherapeutic, in some pts with a refractory course

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitis-- step III step III --




Prospective Randomized Controlled Prospective Randomized Controlled TrialTrial

•• Patients with acute Patients with acute diverticulitisdiverticulitis

•• Exclusion criteria:Exclusion criteria:-- pericolicpericolic airair-- free perforationfree perforation--recent colonoscopyrecent colonoscopy

•• Randomization to colonoscopy :Randomization to colonoscopy :immediate vs. delayedimmediate vs. delayed

Prospective Randomized TrialProspective Randomized Trial62 pts with diverticulitis

Immediate colonoscopy32 pts

Delayed colonoscopy 30 pts

19 colonoscopies3 pts with polyps

32 colonoscopies1 pt with polyp

3 pts waiting8 did not show

CecumCecum not reachednot reached33

CecumCecum not reachednot reached44No complicationsNo complications

ConclusionsConclusions

Patients with acute Patients with acute diverticulitisdiverticulitis::

-- Abdominal CT seems to be sufficientAbdominal CT seems to be sufficient

-- Routine colonoscopy is not advocatedRoutine colonoscopy is not advocated

-- Reserved for pts with a refractory courseReserved for pts with a refractory course

Colonoscopy in acute Colonoscopy in acute diverticulitisdiverticulitis is:is:

feasible but seldom necessaryfeasible but seldom necessary

early colonoscopy in patients with acute diverticulitis ...early colonoscopy in patients with acute...

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