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The first 25 slides, exactly as they appear. The full deck has 180 content slides.
General Surgery
Diverticular Disease and Colonic Volvulus
Built from Maingot's Abdominal Operations
What’s inside
15 sections · 180 slides
Overview
- Scope of this topic
- Terms used in diverticular disease
Diverticular Disease
What the pouches are, why they form, and how often they matter
- Colonic diverticula as a structural abnormality
- <10%
- Changing prevalence and hospital burden
- Early descriptions of colonic diverticula
- Recognition of diverticulitis and its complications
- Established knowledge by the early twentieth century
Why Diverticula Form
Diet, pressure, motility and the ageing bowel wall
- Diverticular disease as a disease of Western populations
- Fibre, intraluminal pressure and wall tension
- Protective factors
- Normal colonic motor patterns
- Evidence from intraluminal manometry
- Myoelectric changes in the colonic wall
- Geographic and ethnic variation
- Right-sided diverticular disease in Asian patients
Structure of the Diseased Colon
Where the pouches sit and what changes in the wall
- Colonic diverticula as false diverticula
- Muscle layers of the colonic wall
- Relationship of the diverticulum to the vasa recta
- Formation of a colonic diverticulum
- Cross section of a sigmoid colon containing diverticula
- Muscle changes described by Whiteway and Morson
- Elastosis and the concertina appearance
- Collagen composition and matrix metalloproteinase 1
- Resected sigmoid colon with diverticula
- Mucosal view of colonic diverticula
- Connective tissue disorders associated with diverticular disease
- Onset of diverticulitis by microperforation
- Progression from blocked diverticulum to peritonitis
Clinical Presentation
The acute attack, the indolent form, and what else it could be
- Frequency of symptoms in diverticulosis
- Features of an acute attack of diverticulitis
- Anatomical mimics of urinary infection and appendicitis
- Physical findings in acute diverticulitis
- Differential diagnosis of left iliac fossa pain
- Initial management of uncomplicated diverticulitis
- Indolent presentation of diverticular disease
- Left colonic diverticula on double-contrast barium enema
- Computed tomography of sigmoid diverticula
- Single sigmoid diverticulum on computed tomography
- Counselling and the limits of elective surgery for symptoms
Complications
Perforation, fistula, bleeding, obstruction and abscess
- Complications of diverticular disease
- Free perforation and feculent peritonitis
- Fistula formation in diverticular disease
- Sites of diverticular fistula
- Colovesical fistula
- Investigation of a suspected colovesical fistula
- Colocutaneous fistula
- Coloenteric and colovaginal fistula
- Diagnosis of colovaginal fistula
- Operative repair of diverticular fistula
- Diverticular haemorrhage
- Why a diverticulum bleeds
- Presentation of diverticular bleeding
- Localising the site of colonic bleeding
- Choice of test in acute lower gastrointestinal bleeding
- Radionuclide scanning and endoscopy in bleeding
- 5%
- Mesenteric angiogram of the sigmoid colon
- Contrast blush of active diverticular bleeding
- Investigation after bleeding has stopped
- Large bowel obstruction from diverticular disease
- Active diverticulitis occluding the colonic lumen
- Confirming obstruction and excluding malignancy
- Management of obstructing diverticular disease
- Diverticular abscess
- Detecting a diverticular abscess
- Treatment of a diverticular abscess
- Limits of percutaneous drainage and the role of laparoscopy
- Paracolic abscess with a percutaneous drainage tube
- Giant colonic diverticulum
- Presentation and treatment of giant colonic diverticulum
- Diverticular disease and colorectal cancer
Investigations
What imaging adds, and when it must be avoided
- Computed tomography in acute diverticular disease
- Water-soluble contrast studies
- Contrast extravasation into an abscess cavity
- Contrast enema in fistula and the danger of barium
- Role of ultrasound scanning
- Assessment of the colon after a first attack
- Additional tests for fistulous disease
Grading the Severity
The Hinchey classification and its modern subdivisions
- The Hinchey stages of diverticulitis
- Reading the Hinchey classification
- Modified Hinchey classification
- Purpose of the modified stages
Medical Management
Antibiotics, senior decisions, and a shift away from resection
- Antibiotic therapy for acute diverticulitis
- Deciding to operate
Elective Surgery
Who benefits, what the recurrence figures actually show
- Selecting patients for elective resection
- The two-attack rule and its origins
- Recurrence figures quoted for diverticulitis
- Evidence against routine prophylactic resection
- Nature of recurrent attacks
- Outcomes after elective resection
- Risk-reducing measures before elective surgery
- Diverticular disease in patients under 50 years
- The challenge to aggressive surgery in young patients
- Readmission and unnecessary operation in young patients
- Diverticular disease in immunocompromised patients
- Outcome of diverticulitis after immunosuppression
- Measures that may reduce recurrent attacks
The Acute Abdomen
Localised peritonitis, generalised peritonitis and the operative choices
- Acute diverticulitis with localised peritonitis
- Progress on conservative treatment
- Mortality in complicated diverticulitis
- Acute diverticulitis with generalised peritonitis
- Nonoperative management in the unfit patient
- Trial of resuscitation before operating
- Resection versus nonresection in feculent peritonitis
- Laparoscopic lavage in the emergency setting
- Extent of resection
- Deciding whether to anastomose in the acute setting
- Hartmann's procedure
- Risks of restoring bowel continuity
- Primary anastomosis in the emergency setting
- Hartmann's procedure compared with primary anastomosis
Laparoscopic Surgery
Where keyhole surgery has taken over, and what it costs
- Laparoscopic surgery in colorectal disease
- Laparoscopic exploration and drainage
- Laparoscopic colonic resection for diverticular disease
- Reported laparoscopic outcomes and publication bias
- US$3458
- Summary of diverticular disease
- Unresolved questions in diverticular disease
Colonic Volvulus
A loop of colon twisted on its own mesentery
- Definition of colonic volvulus
- Epidemiology of colonic volvulus
- Age and sex distribution
- Predisposing factors for colonic volvulus
- Anatomical basis of volvulus at different sites
- Closed-loop obstruction in colonic volvulus
- Caecal volvulus and caecal bascule
- Ileosigmoid knotting
- Clinical presentation of colonic volvulus
- Complications of colonic volvulus
- Plain radiography in colonic volvulus
- Plain film signs of sigmoid and caecal volvulus
- Sigmoid volvulus on plain supine abdominal radiograph
- Caecal volvulus with proximal small bowel obstruction
- Contrast enema and the bird beak sign
- Computed tomography in colonic volvulus
- Swirl sign of sigmoid volvulus on computed tomography
- Beaking at the site of sigmoid volvulus
- Beaking effect in caecal volvulus
- Endoscopy as a diagnostic and therapeutic tool
- Mortality of colonic volvulus
- Principles of management in colonic volvulus
- Endoscopic decompression of sigmoid volvulus
- Technique of endoscopic decompression
- Definitive surgery for recurrent sigmoid volvulus
- Nonresectional operations for sigmoid volvulus
- Options for the patient unfit for anaesthesia
- Laparoscopic options in sigmoid volvulus
- Management of caecal volvulus
- Outcomes of operations for caecal volvulus
- Cecostomy tube fixation of an untwisted caecal volvulus
- Sigmoid volvulus compared with caecal volvulus
- Conclusions on colonic volvulus
Takeaways
What to carry away from both conditions
- Key points on diverticular disease
- Key points on colonic volvulus
References
The source list for this topic
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- Maingot's Abdominal Operations, 12th Edition