Diverticula of the Alimentary Tract - PowerPoint Presentation

Slide1

Diverticula of the Alimentary Tract

Aaron Sinclair, MDSlide2

Learning Objectives

Differentiate between true and false diverticula.

Review pathophysiologic development of different diverticula.

Evaluate the locations of common diverticula of the alimentary tract.

Assess different diagnostic modalities for diverticula.

Discuss

when treatment is indicated for diverticula.Slide3

Normal AnatomySlide4

http://www.bing.com/images/search?q=false+diverticulum&view=detailv2&qpvt=false+diverticulum&id=7FF679420026BBF80510055167A0720E75EDA50E&selectedIndex=0&ccid=cBNI2qeg&simid=608039890951996806&thid=OIP.M701348daa7a0c137b30f6bebf4532517o0Slide5

Diverticula of the Esophagus

Upper Esophagus

Zenker’s

Middle Esophagus

Traction

Lower Esophagus

EpiphrenicSlide6

Upper Esophagus – Zenker’s

Diverticulum

False Diverticulum

Upper Posterior Esophagus – Killian’s TriangleSlide7

http://emedicine.medscape.com/article/374153-overview

http://emedicine.medscape.com/article/374153-overview

Upper Esophagus –

Zenker’s

Diverticulum

Etiology – unknown, ? Acid and Swallowing dysfunction.

Age predominately > 60 Incidence 2/100,000Slide8

http://www.gastrolab.net/y0157.jpg

Upper Esophagus –

Zenker’s

Diverticulum

Diagnosis – preferred barium swallow

Caution with endoscopy due to perforation riskSlide9

Zenker's Diverticulum Ryan

Law,David

A.

Katzka

, Todd H. Baron Published Online: September 19, 2013

http://dx.doi.org/10.1016/j.cgh.2013.09.016

Upper Esophagus –

Zenker’s

Diverticulum

Treatment

Traditional Surgical Management

Endoscopic

Cricopharyngeal

Myotomy

Symptom Improvement as high as 90%

Recurrence in up to 35%Slide10

Middle Esophagus – Traction Diverticulum

True Diverticulum

Mediastinal lymphadenopathy scarring

 tractionSlide11

http://www.gastrohep.com/images/image.asp?id=720

Middle Esophagus – Traction Diverticulum

Usually < 2 cm in size

Treatment rarely needed unless complications occur

Fistulas

OcclusionSlide12

Lower Esophagus –

Epiphrenic

Diverticulum

False Diverticula

Rare = .015% of the population

Occurs within 10 cm of Lower Esophageal StrictureSlide13

Lower Esophagus –

Epiphrenic

Diverticulum

Etiology = GERD + Motility Dysfunction ?

Treatment = typically not indicated if < 5 cm & asymptomatic

Therapy:

Fundoplication (GERD)

Open Resection or LaparoscopicSlide14

Gastric Diverticulum

True Diverticulum

Rare - .04%

Usually asymptomatic but can lead to complications:

Bleeding

Dyspepsia

Emesis Slide15

http://www.eurorad.org/eurorad/view_figure.php?pubid=11721&figid=36787&nr=1&lang=en

Gastric Diverticulum

Treatment – conservative for symptomatic patients only

Proton Pump Inhibitors

Definitive Treatment – Gastrectomy of the DiverticulumSlide16

http://www.gastrolab.fi/videos/vid3065.jpg

Duodenal Diverticula

True or False Diverticula

Common – 22% of population

Most common location is 2

nd

part

Can lead to complications due to location

Obstuction

Sphincter of Oddi

Impingement of

Hepato

-

biliary tree Slide17

http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=105730&ti=324613&searchkey=

Duodenal Diverticula

Diagnosis

Endoscopy

Small Bowel Follow Through

MRI or CT scan

Endoscopy

Treatment

Asymptomatic – nothing

Dependent on symptoms

http://www.gastrolab.fi/videos/vid3063.jpgSlide18

http://openi.nlm.nih.gov/imgs/512/211/2988864/2988864_crg0004-0492-f03.png

Jejunal

and

Ileal

Diverticula

False Diverticula

Occur anywhere along the Jejunum or Ileum

Typically on the mesenteric side of the bowel at blood vessel penetration

Most are found incidentally

Symptoms may include

Bleeding

Obstruction

Infection

?Bacterial

overgrowth

.

Diverticulitis

Jejunal Diverticulitis: A Rare Case of Severe Peritonitis.

Sakpal

SV, Fried K, Chamberlain RS - Case Rep

Gastroenterol

(2010) Slide19

Jejunal Diverticulosis: Findings on

CT in 28 Patients

Florian

Fintelmann

1

Marc S. Levine

Stephen E.

Rubesin

http://

www.ajronline.org/doi/pdfplus/10.2214/AJR.07.3087

AJR:190, May 2008

http://pillcamkorea.co.kr/board/image_viw.asp?key=106&page=5

Jejunal

and

Ileal

Diverticula

Diagnosis:

Capsule Endoscopy

Small Bowel Barium Contrast Follow Through

Treatment

Antibiotics

Promotility Agents

ResectionSlide20

http://emedicine.medscape.com/article/194776-overview#a2

Meckel’s Diverticula

True Diverticula

Rule of 2’s

2% of the population

2 feet from the ileocecal valve

2:1 male predominance

2% are symptomatic

May have ectopic tissues

Symptoms

may include

Bloody Mucoid stools

Abdominal pain

Nausea and vomiting under a

ge 6Slide21

Meckel’s Diverticula

Diagnosis:

Adults – high degree of suspicion –

technectium

99m scan

Children

Ultrasound

Can fix intussusception - 90%

CT Scan

Treatment

Based on Age and Symptoms

5 fold increase in complications

Bowel Obstruction

Infection

Asymptomatic – remove

Age <50 or young children

Palpable abnormality

Size >2 cm (length or base)Slide22

Colonic Diverticula

False Diverticula

Arteries penetrate the muscularis to reach the submucosa and mucosa – weak pointSlide23

Colonic Diverticula

Decreased fiber leads to an increase in colonic wall pressures.

Low fiber

 colonic wall hypertrophy

LaPlace’s

Law – Increased pressure

at smaller diameter (sigmoid)Slide24

http://www.drugs.com/health-guide/diverticulosis-and-diverticulitis.html

Colonic Diverticula

Incidence

Age 40 20% of all people

Age 80 60% of all people

80% asymptomatic with diverticulosis

15% to 20%



diverticulitis

5% to 10%

 diverticular

bleeding 

Diagnosis

CT Scan

Endoscopy

Radionucleide

Imaging

Barium EnemaSlide25

Colonic Diverticula

Treatment

Strong Associations

Fiber – A

Harvard study of 47,888 men demonstrates the role of dietary fiber. Men who consumed the most fiber were 42% less likely to develop symptomatic diverticular disease than their peers who consumed the least fiber. 

Weak Associations

Increasing Exercise

Increasing Water Intake

Decreasing Low Fat/High Meat DietSlide26

References

Aggerholm

K,

Illum

P. Surgical treatment of Zenker's diverticulum. J

Laryngol

Otol. 1990 Apr;104(4):312-4.

Aldoori et al. A Prospective Study of Dietary Fiber Types and Symptomatic Diverticular Disease in Men. J. Nutr. 128: 714–719, 1998

Choi

JJ,

Ogunjemilusi

O,

Divino

CM. Diagnosis and management of diverticula in the jejunum and ileum. Am Surg. 2013 Jan;79(1):108-110

Fry R, Mahmoud N,

Maron

D, et al. Townsend:

Sabiston’s

Textbook of surgery. Rev. Ed. 19

th

Edition, 1309-1314. Jacobs DO. Clinical Practice. Diverticulitis. N Engl J Med. 2007 Nov 15;357(20):2057-66.Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006 Feb 4;332(7536):271-5.

Kilic

A,

Schuchert

MJ,

Awais

O, et al. Surgical management of

epiphrenic

diverticula in the minimally invasive era. JSLS. 2009 Apr-Jun;13(2):160-4.

Maish, M. Townsend:

Sabiston’s

Textbook of surgery. Rev. Ed. 19

th

Edition,1023-1025. 

Martinez-Cecilia D,

Arjona

-Sanchez A, Gomez-Alvarez M, et al. Conservative management of perforated duodenal diverticulum: a case report and review of the

literature.World

J

Gastroenterol

. 2008 Mar 28;14(12):1949-51.

Mohan

P,

Ananthavadivelu

M,

Venkataraman

J. Gastric diverticulum. CMAJ. 2010 Mar 23;182(5):E226.

Morris AM,

Rogenbogen

SE,

Hardiman

KM,

Hendren

S. Sigmoid diverticulitis: a systematic review. JAMA. 2014;311(3):287-297

Mulder CJ,

Costamagna

G, Sakai P. Zenker's diverticulum: treatment using

a flexible

endoscope. Endoscopy. 2001 Nov;33(11):991-7.

Park JJ, Wolff BG,

Tollefson

MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005 Mar;241(3):529-33.

Shahedi

K1, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.

Clin

Gastroenterol

Hepatol

. 2013 Dec;11(12):1609-13.

Strate

LL. Lower GI bleeding: epidemiology and diagnosis.

Gastroenterol

Clin

North Am. 2005 Dec;34(4):643-64.

Weizman

AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J

Gastroenterol

. 2011 Jul;25(7):385-9.

Zani A, Eaton S, Rees CM,

Pierro

A. Incidentally detected Meckel diverticulum: to resect or not to resect? Ann Surg. 2008 Feb;247(2):276-81.