Diverticular Disease
Diverticulitis due to Fish Bone

Video Endoscopic Sequence 1 of 8.

Diverticulitis due to Fish Bone, A colonoscopy was performed

This is a 85 year-old lady, had suffered from recurrent abdominal pain, since three years, in the left iliac fossa, the physical examination found, a marked tenderness in the left iliac fossa.

Fish bones are the most common foreign objects leading to bowel perforation. Most cases are confined to the extraluminal space without penetration of an adjacent organ. However, abscess formation due to the perforation of the rectosigmoid colon by a fish bone can lead to the penetration of the urinary bladder and may subsequently cause the fish bone to migrate into the urinary bladder.


For more endoscopic details, download the video clip by clicking on the endoscopic image. Wait to be downloaded complete then Press Alt and Enter for full screen. All endoscopic images shown in this Atlas contain video clips. We recommend watch the video clips in full screen mode.

 

Diverticulitis due to Fish Bone

 

 

Colonoscopy of Diverticulitis due to Fish Bone

Video Endoscopic Sequence 2 of 8.

Colonoscopy of Diverticulitis due to Fish Bone

A colonic haustra, That is edematous, with signs of inflammation and fibrinoid secretion.

Fish bone ingestion is relatively common, however, resultant perforation of the small bowel is fortunately rare.

Colonoscopy of Diverticulitis due to Fish Bone

Video Endoscopic Sequence 3 of 8.

A white halo which is produced by a fibrinoid. secretion, is observed.

Any insoluble ingested foreign body may potentially cause bowel perforation, however the most commonly unintentionally ingested foreign bodies are fish bones, toothpicks, chicken bones and fragments of bone. Perforation may occur at any site along the gastrointestinal tract with varying clinical presentations. However it must be noted that most ingested foreign bodies pass spontaneously through the gastrointestinal tract without impaction or perforation or need for surgical intervention.

Colonoscopy of Diverticulitis due to Fish Bone

Video Endoscopic Sequence 4 of 8.

Colonoscopy of Diverticulitis due to Fish Bone

More pictures and videos of this endoscopic sequence.

Fish bone stuck in one of the diverticula is observed.

The ingestion of a foreign body (FB) is not uncommon and often goes unnoticed. The majority of FBs that pass into the stomach traverse the gastrointestinal tract without complication. Less than 1% of FBs cause perforation, depending on the size and type of the FB. The most common perforation site is the terminal ileum, followed by the rectosigmoid junction. Fish bones are the most commonly observed objects that result in bowel perforation.

 

Colonoscopy of Diverticulitis due to Fish Bone

Video Endoscopic Sequence 5 of 8.

Colonoscopy of Diverticulitis due to Fish Bone

Using a special forceps to remove foreign bodies. The fish bone is handled, successfully extracted.

Two hemoclip are placed to close possible micropreforations

Video Endoscopic Sequence 6 of 8.

Two hemoclip are placed to close possible micropreforations

 

Both hemoclips are placed

Video Endoscopic Sequence 7 of 8.

Both hemoclips are placed

Endoclip application can be challenging, and the success rate can depend on the colonoscopist, presence of fecal contamination, and the size and site of the perforation

Image of fish bone is observed

Video Endoscopic Sequence 8 of 8.

Image of fish bone is observed

The inadvertent swallowing of foreign bodies is common, but rarely results in perforation of the gastrointestinal tract. Because any site of the gastrointestinal tract may be perforated by a foreign body, the clinical presentation may vary and mimic diverse medical conditions.

To enlarge image press on it

 

 

 

 

 

 

Colonoscopy in Retroflexion of Diverticulae

Video Endoscopic Sequence 1 of 1.

Colonoscopy in Retroflexion of Diverticulae

A colonoscopy performed in retroflexion from the cecum to the sigmoid.

Download the the video clip.

 

 

 

diverticulitis

Video Endoscopic Sequence 1 of 3.

Colonoscopy of Colon Sigmoid diverticulitis

This is a 38 year-old female, presented with abdominal pain in the left iliac fossa, physical examination found sensitivity in the left iliac fossa and elevation of the leukocyte formula
a colonoscopy was performed, finding this image and video clip.

 

 

 

 

diverticulitis

Video Endoscopic Sequence 2 of 3.

Purulent secretion is observed in the sigmoid area.

 

 

 

Colonoscopy of Colon Sigmoid diverticulitis

Video Endoscopic Sequence 3 of 3.

Colonoscopy of a Diverticulitis

Diverticular Colitis

Video Endoscopic Sequence 1 of 7.

Diverticular Colitis

This 84 year-old female was hospitalized during 10 days in a hospital in the Republic of The United States of America due to a diverticulitis, 45 days after the patient was discharged from the hospital, a colonoscopy was performed finding those images and video clips of this endoscopic sequence.

 

 

 

 

 

 

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 2 of 7.

Colonoscopy of a Diverticular Colitis

Infrequently, patients with diverticular disease develop a segmental colitis most commonly in the sigmoid colon. The endoscopic and histologic features vary, ranging from mild inflammatory changes with submucosal hemorrhages (peridiverticular red spots on colonoscopy sometimes referred to as "Fawaz spots") to florid, chronic active inflammation resembling (histologically and endoscopically) inflammatory bowel disease The pathogenesis is incompletely understood. The cause may be multifactorial, related to mucosal prolapse, fecal stasis, or localized ischemia.

 

 

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 3 of 7.

CLINICAL MANIFESTATIONS

Patients may be asymptomatic or have features resembling those seen in patients with segmental colitis including hematochezia and abdominal pain.

 

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 4 of 7.

Colonoscopy of a Diverticular Colitis

Diagnosis is made histologically and endoscopically. The differential diagnosis includes inflammatory bowel disease, infectious colitis, NSAID-induced colitis, and ischemic colitis, which can usually be distinguished based upon the clinical context. However, distinction from IBD may not always be straightforward particularly since the histologic features of IBD (such as neutrophilic cryptitis, crypt abscesses and distorted crypt architecture) may all be present. Evidence of Crohn's disease elsewhere in the gastrointestinal tract can provide an important clue.

 

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 5 of 7.

Colonoscopy of a Diverticular Colitis

The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Because diverticula and, hence, diverticulitis can develop anywhere in the gastrointestinal tract, symptoms may mimic multiple conditions.

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 6 of 7.

Diverticulitis in the right colon or in a redundant sigmoid colon may be mistaken for acute appendicitis. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similar to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecological process.

Mild diverticulitis presents with localized abdominal pain, commonly left lower quadrant pain. Pain is often described as crampy and may be associated with a change in bowel habits. A microperforation, most likely walled-off by adjacent structures, may present with no systemic signs of illness or infection.

 

Colonoscopy of a Diverticular Colitis

Video Endoscopic Sequence 7 of 7.

Colonoscopy of a Diverticular Colitis

The sigmoid colon, where colonic intraluminal pressures are greatest, is most commonly affected. Depending on the location of the affected diverticulum, abscesses may form peritoneally or retroperitoneally. The sigmoid and transverse colon and the anterior surface of the ascending and descending colon are intraperitoneal. The posterior surface of the right and left colon is located retroperitoneally.

 

Colonoscopy of Colon Sigmoid diverticulitis

Video Endoscopic Sequence 1 of 1.

Colonoscopy of Colon Sigmoid diverticulitis

This a 79 year-old female, who im a colonoscopy is detected this fibropurulent secretion which emerges from a sigmoid diverticulum.

Diverticulitis is a common condition occasionally complicated by abscess formation. Small abscesses may be managed by antibiotic therapy alone.

 

bleeding diverticulosis

Video Endoscopic Sequence 1 of 13.

Lower gastrointestinal bleeding due to diverticulosis.

Massive bleeding from the lower digestive tract due to diverticulosis. Severe diverticular bleeding treated with epinephrine injection.

This is an 84 year-old-male, who in a period of ten years had three hospitalizations because of enterorrhagia due to a diverticular disease, this time he was admitted for recurrence of the bleeding, the day before had made a previous colonoscopy, which found diverticulosis throughout the entire colon including some diverticulae of the terminal ileum, no finding the exact site of bleeding.

Because of the recurrence of the bleeding the next day, an emergency colonoscopy was performed.

The endoscopic image shows a white part where this adrenaline solution is injected.

bleeding diverticulosis

Video Endoscopic Sequence 2 of 13.

In the sigmoid, bright red blood is observed, which is the probable site of bleeding.

Pathogenesis: A characteristic angioarchitecture is associated with bleeding colonic diverticula. As a diverticulum herniates, the penetrating vessel responsible for the wall weakness at the point of herniation becomes draped over the dome of the diverticulum, separated from the bowel lumen only by mucosa. Over time, the vasa recta is exposed to recurrent injury along its luminal aspect, leading to eccentric intimal thickening and thinning of the media. These changes may result in segmental weakness of the artery, predisposing to rupture into the lumen. It is rare for bleeding to coexist with diverticulitis.

 

 lower GI bleeding

Video Endoscopic Sequence 3 of 13.

Diverticular bleeding is a common cause of lower gastrointestinal hemorrhage. Patients typically present with massive and painless rectal hemorrhage. If bleeding is severe, initial resuscitative measures should include airway maintenance and oxygen supplementation, followed by measurement of hemoglobin and hematocrit levels, and blood typing and crossmatching. Patients may need intravenous fluid resuscitation with normal saline or lactated Ringer's solution, followed by transfusion of packed red blood cells in the event of ongoing bleeding. Diverticular hemorrhage resolves spontaneously in approximately 80 percent of patients, Re-bleeding rates range from 22-38%. If there is severe bleeding or significant comorbidities, patients should be admitted to the intensive care unit.

 

Gastrointestina Hemorrhage

Video Endoscopic Sequence 4 of 13.

An image of the suspect responsible for the bleeding site is observed, there is a long blood clot that emerges from a diverticulum.

The recommended initial diagnostic test is colonoscopy, performed within 12 to 48 hours of presentation and after a rapid bowel preparation with polyethylene glycol solutions. If the bleeding source is identified by colonoscopy, endoscopic therapeutic maneuvers can be performed. These may include injection with epinephrine or electrocautery therapy. If the bleeding source is not identified, radionuclide imaging (i.e., technetium-99m-tagged red blood cell scan) should be performed, usually followed by arteriography. For ongoing diverticular hemorrhage, other therapeutic modalities such as selective embolization, intra-arterial vasopressin infusion, or surgery, should be considered.

Colonic diverticular bleeding

Video Endoscopic Sequence 5 of 13.

Therapeutic endoscopy was performed with injection of . diluted epinephrine 1: 10.000 injecting some diverticulae 0.25 ml.

Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding in adults. In most cases, the bleeding will stop spontaneously. However, if the bleeding persists, endoscopic, radiologic, or surgical intervention may be required.

Colon carcinoma is the most common source of lower gastrointestinal blood loss, but the bleeding is often occult (ie, no evidence of visible blood loss to the patient or clinician). On the other hand, colonic diverticular bleeding is the most common cause of brisk hematochezia (maroon or bright red blood), accounting for 30 to 50 percent of cases of massive rectal bleeding.

 

massive rectal bleeding

Video Endoscopic Sequence 6 of 13.

The suspected site of bleeding in the sigmoid, is being injected.

Risk factors for hemorrhage include the use of NSAIDs, lack of dietary fiber, constipation, and advancing age.10-12 Bleeding usually ceases spontaneously, with less than 1% of patients requiring greater than 4 units of blood.9 However, bleeding can become more hemodynamically significant in elderly patients with comorbid conditions, such as cerebrovascular disease or atherosclerotic cardiovascular disease, and in those with polypharmacy who may be taking anticoagulants or NSAIDs.

Gastrointestina Hemorrhage

Video Endoscopic Sequence 7 of 13.

Another image and video clip of the blood clot which emerges from the suspect diverticula.

 

Gastrointestinal Bleeding

Video Endoscopic Sequence 8 of 13.

Another image and video clip of the site that is suspected of bleeding.

Hemorrhage ceases spontaneously in 70-80% of patients. Re-bleeding rates range from 22-38% If bleeding stigmata, such as a protuberant vessel or pigmented spots, associated with a diverticulum are visualized during colonoscopy, therapy can be applied directly to this area. A small, retrospective study of endoscopic therapy in 10 patients found no rebleeding episodes using a combination of epinephrine injection and electrocautery therapy. Endoscopically placed clips (endoclips), fibrin sealant, and band ligation were shown to be effective in controlling diverticular bleeding in some small case series.

If colonoscopy is not available or if it fails to reveal or control the bleeding source, further intervention is required. A tagged red blood cell scan is typically performed with attempts to localize the bleeding source and assist with targeted therapy by arteriography or surgery.

 lower GI bleeding

Video Endoscopic Sequence 9 of 13.

Another image shows several diverticulae

Gastrointestinal Bleeding

Video Endoscopic Sequence 10 of 13.

More pictures and video clips of sigmoid colon

Gastrointestinal Bleeding

Video Endoscopic Sequence 11 of 13.

Status subsequent injection of adrenaline

lower GI bleeding

Video Endoscopic Sequence 12 of 13.

Appearance after injections of epinephrine solution

Gastrointestina Hemorrhage

Video Endoscopic Sequence 13 of 13.

A subsequent appearance to the injection of adrenaline solution

 

 

Diverticulitis Aguda

Video Endoscopic Sequence 1 of 6.

Acute Diverticulitis

This is an 80 year-old male, whom was referred to our endoscopic unit due to a left flank mass that was suspected in abdominal ultrasound, colonoscopy is practiced finding this pseudo tumor.

 

 

Acute Diverticulitis

Video Endoscopic Sequence 2 of 6.

Within this lesion a fibro-purulent secretion is displayed

 

Acute Diverticulitis

Video Endoscopic Sequence 3 of 6.

Another image of diverticulitis as well as the video clip

 

 

Idiopatic  rectal ulcer

Video Endoscopic Sequence 4 of 6.

Idiopathic ulcer is observed in the dentate line

In addition to diverticulitis the patient has idiopathic ulcer in the dentate line and internal hemorrhoids.

 rectal ulcer

Video Endoscopic Sequence 5 of 6.

Retroflexed Image there are internal hemorrhoids and also the ulcer is observed.

 

 

 rectal ulcer

Video Endoscopic Sequence 6 of 6.

Another image of the ulcer in the dentate line

Intradiverticular divertículos.

Video Endoscopic Sequence 1 of 3.

Intradiverticular diverticulum

Two small "daughter" diverticulum inside a sigmoid diverticulum, large diverticula may contain smaller diverticula.

This 64 year-old male has medical history that has diverticular disease since the age of 21.

 

Big diverticulum with Fecalith (Filled with Faeces)

Video Endoscopic Sequence 2 of 3.

Big diverticulum with Fecalith (Filled with Faeces)

Inspissated stool or a fecalith within a thin walled diverticulum will cause erosion and inflammation leading to infection and perforation. This may vary from a minimal peridiverticular phlegmon, which progresses to a peridiverticular or mesenteric abscess, which may then become a walled off pelvic or intra-abdominal abscess, to one that perforates into the free peritoneal cavity causing generalized peritonitis. Usually only one diverticulum becomes inflamed leading to the different stages of inflammation noted.

 

Endoscopic Image of Diverticulum

Video Endoscopic Sequence 3 of 3.

Endoscopic Image of Diverticulum

Diverticular disease is rare in people younger than 40 years. Disease is more virulent in young patients, with a high risk of recurrences or complications. Obesity is an important risk factor in young people.

 

Diverticular Disease.

Diverticular Disease.

Endoscope view of the colon affected by diverticular disease. It causes sacs (in brown) to form and protrude from the colon wall.

Colon Diverticulae, diverticular disease, showing small outpouching and circular muscle hypertrophy. The number of diverticula that a person may have varies from one to hundreds and it is most common in the left colon, primarily the sigmoid.

 

Colonic diverticular disease

Video Endoscopic Sequence 1 of 3.

Colonic diverticular disease

Scattered Patches of dark erythematous mucosa. The dark appearance of the patches suggest that the acute phase has passed.

Colonic diverticular disease is a common problem in the Western world. The incidence of the disease increases with age but only a minority of these patients are symptomatic. Complications of diverticular disease, however, can cause significant morbidity and mortality. Studies about the natural history of diverticular disease, and the incidence of complications after an initial attack, have reported varying outcomes.

 

Colonic diverticular disease

Video Endoscopic Sequence 2 of 3.

Endoscopic Image of Colon Diverticulae

Scattered Patches of dark erythematous mucosa are displayed in the both images of this sequence. However small red fold in diverticular disease are common and related to strong muscular contractions, associated with the high pressure segment in the sigmoid.

 

Intradiverticular diverticulum.

Video Endoscopic Sequence 3 of 3.

Intradiverticular diverticulum.

Some large diverticula can have a small "daughter", inside a sigmoid diverticulum. A diverticulum (if there are more than one they are known as "diverticula") is a protrusion of the inner lining of the intestine through the outer muscular coat, forming a small pouch with a narrow neck. The commonest site for diverticula to develop is the lower left part of the colon.
The presence of diverticula is often referred to as diverticulosis.
Most diverticula develop during later life and are more and more common with increasing age. But can form anywhere in the large intestine. Once these pouches form they remain for life but frequently cause no problems.

 

Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 1 of 2.

Diverticulitis of the Sigmoid.

A 58 year-old male, presenting with abdominal pain in the left iliac fosa, fever, chills and a the white blood cell count was of 15000, with neutrofilia. The endoscopic image was found on the sigmoid, showing mucopurulent exudate and edema.In some rural areas of the world, particularly in Africa,diverticula are rarely seen.

 

Diverticular Disease of the Sigmoid Colon

Video Endoscopic Sequence 2 of 2.

Diverticular Disease of the Sigmoid Colon

The image and the video clip display a diverticulitis of the sigmoid, showing a mucopurulent exudate and edema.

The most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications. 

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 1 of 4.

Endoscopic View of Diverticulitis of the Sigmoid.

A 43 year-old male, presented with adynamic Ileum, rebound tenderness in the left lower abdominal quadrant, abdomen distended and tympanic to percussion. This endoscopic findings are inespecific but consistent of diverticular disease. There is also a pseudo tumor appearance. The cat scan displayed thickened colonic walls of the sigmoid.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 2 of 4.

More images and videos concerning this case. Endoscopically an inflammatory process with an erythematous mucosa with interstitial edema is observed. The clinical picture was consistent of colonic diverticulitis.

Acute diverticulitis traditionally has been considered a disease of patients more than 50 years old by many authorities It has been considered a rare diagnosis in a young adult presenting with abdominal pain, with few reports in the published literature. In one report, acute diverticulitis was considered more aggressive in younger patients than in older adults.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 3 of 4.

The rectal mucosa displays several inespecific ulcerated lesions.

Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 4 of 4.

The sigmoid and descending colon show signs of diverticulitis.

Diverticulitis is defined as an inflammation of one or more diverticula. Fecal material or undigested food particles may collect in a diverticulum. Obstruction of the neck of the diverticulum results in distension of the pouch secondary to mucous secretion and overgrowth of normal colonic bacteria. The thin-walled diverticulum, consisting solely of mucosa, is susceptible to vascular compromise and subsequent microperforation or macroperforation. This perforation may be the initiating event leading to symptomatic diverticular diseases. Disease is frequently mild when pericolic fat and mesentery wall-off a small perforation. More extensive disease leads to abscess formation and rarely, with rupture, to peritonitis.


 

Acute Diverticulitis.

Video Endoscopic Sequence 1 of 5.

Acute Diverticulitis.

This 65 year old male. He had presented three days previously with abdominal pain, fever, chills, and leukocytosis, left lower quadrant tenderness with rebound.

The image and the video show a diverticula with signs of acute inflammation with suspicion of micro perforation.

 

Acute Diverticulitis.

Video Endoscopic Sequence 2 of 5.

Another image and video of that diverticula which has suspicion of micro perforation, there are some fecaliths in the diverticulae nearby.

 

Acute Diverticulitis.

Video Endoscopic Sequence 3 of 5.

This image as well as the video clip is seen with magnifying colonoscope.
The tiny hole is observed which has suspicion of micro perforation.

Acute Diverticulitis.

Video Endoscopic Sequence 4 of 5.

Using of TriClip, Endoscopic Clipping Device.

Due to the suspicion of micro perforation of the diverticula.
We used a clipping device to close the micro perforation.

 

Acute Diverticulitis.

Video Endoscopic Sequence 5 of 5.

Final status of closing the micro perforation.

The patient was managed as an ambulatory basis with wide spectrum antibiotics, improving the clinical course.

 

Diverticulitis.

Video Endoscopic Sequence 1 of 4.

Diverticulitis.

This is a 75 year-old male, presented with adynamic Ileum, abdominal pain, rebound tenderness and the cat scan displayed a peridiverticular abscess.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 2 of 4.

Endoscopic View of Diverticulitis of the Sigmoid.

Inflamed diverticulum with mucopurulent exudated, erythematous and swollen mucosa. Colonoscopy revealed focal diverticulitis: peridiverticular inflammation with scant exudate.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 3 of 4.

This patient presented multiple foci of diverticulitis, this endoscopic sequence displayed at least 3 diverticulum that showed diverticulitis.

 

Endoscopic View of Diverticulitis of the Sigmoid.

Video Endoscopic Sequence 4 of 4.

Acute diverticulitis is the most common complication of colonic diverticulosis and is one of the most frequently encountered acute diseases of the colon. It begins as a localized intramural infection in a segment affected by diverticulosis, with subsequent development of localized pericolic inflammation. Colonic perforation, abscess formation, or generalized peritonitis may occur Colonic strictures and fistulas to other organs are other important complications. Serious complications are more likely if acute diverticulitis is initially unrecognized or misdiagnosed.

 

Inverted diverticulum

Video Endoscopic Sequence 1 of 3.

Inverted diverticulum

 

 

Diverticulitis due to Fish Bone

Inverted diverticulumDivertículo Invertido

Video Endoscopic Sequence 2 of 3.

Divertículo Invertido

Inverted diverticulum

Video Endoscopic Sequence 3 of 3.

Inverted diverticulum

Colon Diverticula

“ Foot Steps Impression”

The image and the video clip display three diverticulae that they seem a Foot Steps impression.

 

Inverted diverticulum.

Inverted diverticulum.

The video clip displays a moving diverticula back and forward, giving the appearance of being a polyp. In order to watch this case you should download the video clip.

In some cases the inverted diverticulum is not easy to distinguish from a polyp by endoscopy.

 

rectal bleeding.

Video Endoscopic Sequence 1 of 2.

A 70 Year- old female, had rectal bleeding. This diverticula was the cause of severe enterorrhagia.

Pathogenesis of a diverticular bleeding.

The colonic diverticulum which appears to form as a herniation of intestinal mucosa through defect in the colonic wall where penetration of arterioles (vasa recta) occurs. This places the vasa recta adjacent to the neck of the diverticulum. Trauma the scraping of intestinal contents against the neck and dome of a diverticulum, led to repeated damage of its associated vasa recta with weakening and predisposition to rupture and massive bleeding. 

 

Diverticular bleeding

Video Endoscopic Sequence 2 of 2.

Close up of the diverticula. Same case as above Diverticular bleeding usually is self-limited but may be recurrent. The bleeding stopped spontaneously.

Complications of diverticulitis: Diverticulitis can lead to complications such as infections, perforations or tears, blockages, or bleeding. Thesecomplications always require treatment to prevent them fromprogressing and causing serious illness.

Bleeding . When diverticula bleed, blood may appear inthe toilet or in your stool. Bleeding can be severe, but itmay stop by itself and not require treatment. Bleedingdiverticula are caused by a small blood vessel in adiverticulum that weakens and finally bursts. Ifthe bleeding does not stop, surgery may be necessary.

Abscess, Perforation and Peritonitis The infection causingdiverticulitis often clears up after a few days of treatment withantibiotics. If the condition gets worse, an abscess may form inthe colon.An abscess is an infected area with pus that may causeswelling and destroy tissue. Sometimes, the infected diverticulamay develop small holes, called perforations. These perforationallow pus to leak out of the colon into the abdominal area. If theabscess is small and remains in the colon, it may clear up aftertreatment with antibiotics. If the abscess does not clear up withantibiotics, the doctor may need to drain it. To drain the abscess,the doctor uses a needle and a small tube called a catheter. Thedoctor inserts the needle through the skin and drains the fluidthrough the catheter. This procedure is called "percutaneouscatheter drainage" Sometimes surgery is needed to clean theabscess and, if necessary, remove part of the colon. A largeabscess can become a serious problem if the infection leaks outand contaminates areas outside the colon. Infection that spreadsinto the abdominal cavity is called peritonitis. Peritonitis requiresimmediate surgery to clean the abdominal cavity and remove thedamagdpart of the colon. Without surgery, peritonitis can befatal.

Fistula A fistula is an abnormal connection of tissue between twoorgans or between an organ and the skin. When damaged tissuescome into contact with each other during infection, theysometimes stick together. If they heal that way, a fistula forms.When diverticulitis-related infection spreads outside the colon, thecolon's tissue may stick to nearby tissues. The most commonorgans involved are the urinary bladder, small intestine, and skin.The most common type of fistula occurs between the bladder andthe colon. It affects men more than women. This type of fistulacan result in a severe, long-lasting infection of the urinary tract.The problem can be corrected with surgery to remove the fistulaand the affected part of the colon.

Intestinal Obstruction The scarring caused by infection maycause partial or total blockage of the large intestine. When thishappens, the colon is unable to move bowel contents normally.When the obstruction totally blocks the intestine, emergencysurgery is necessary. Partial blockage is not an emergency, so thesurgery to correct it can be planned.

 

Perforation as a complication of acute diverticulitis.

Perforation as a complication of acute diverticulitis.

There is a continuum of perforation from micro perforation, which is presumably an igniting step in acute diverticulitis and which occurs well before there is evolution to a visible peridiverticular abscess.

To see the air bubbles that emerges from the perforated diverticula, download the video clip by clicking on the image.

 

Rectal Diverticula.

Rectal Diverticula.

A 53 year-old female, whose the entire colon has diverticular disease, and no segment above the rectum was free of it.

The image and the video clip display a rectal diverticula that is not frequently observed.

 

Diverticular bleeding.

Video Endoscopic Sequence 1 of 4.

Diverticular bleeding.

It is usually sudden in onset, painless and substantial. Diverticulosis is the cause in 30 to 50 percent of cases with massive bleeding from the colon. However, the bleeding stops spontaneously in most patients. In some cases, the bleeding may continue intermittently for a few hours to a few days before resolving.

 

 

 

diverticulosis with

Video Endoscopic Sequence 2 of 4.

This image and the video clip display a diverticulosis with active bleeding.
Lower GI bleeding from diverticulosis occurs in the form of bright red-colored or wine-colored stools.

 

diverticulosis with

Video Endoscopic Sequence 3 of 4.

Signs of recent diverticular bleeding include: active bleeding, visible vessel, adherent clot

 

diverticulosis with

Video Endoscopic Sequence 4 of 4.

A fecalith is seen at the sigmoid.

Causes of major lower GI bleed
Very common
Diverticular disease
Angiodysplasia Less common
Ischemia
Neoplasia
Inflammatory bowel disease
Hemobilia
Perianal disease
Aortoenteric fistula
Solitary rectal ulcer.

 

 

 

 

Diverticulitis of Ileocecal Valve.

Video Endoscopic Sequence 1 of 5.

Diverticulitis of Ileocecal Valve.

An unusual endoscopic finding

A 50 year-old male with abdominal pain and a palpable mass in the right lower quadrant, the ultrasound examination displays a mass in the cecum. The ileocecal valve is observed with inflammatory processes, giving the image of a pseudo tumor, Unusual appereance. There are multiple diverticulae in the cecum and ascending colon one of them with diverticulitis.

Differential diagnosis of this image: lipohyperplasia or lipoma.

 

Diverticulitis of Ileocecal Valve.

Video Endoscopic Sequence 2 of 5.

.The ascending colon a diverticula with diverticulitis is observed there are edema and purulent secretion.

 

Scattered Patches of dark erythematous mucosa

Video Endoscopic Sequence 3 of 5.

Scattered Patches of dark erythematous mucosa

 

At the cecum multiple diverticulae are observed.

Video Endoscopic Sequence 4 of 5.

At the cecum multiple diverticulae are observed.

 

Terminal ileum.

Video Endoscopic Sequence 5 of 5.

Terminal ileum.

Although the ileocecal valve is found with inflammatory processes, the terminal ileum was observed.

 

Colovesical fistula secondary to sigmoid diverticulitis.

Video Endoscopic Sequence 1 of 8.

Colovesical fistula secondary to sigmoid diverticulitis.

This 72-year-old male has been diagnostic having a colovesical fistula patient presented with intermittent fecaluria.

Cystography shows the bladder and revealed presence of multiple small diverticulae along sigmoid colon.

Cystography may demonstrate contrast outside the bladder but is less likely to demonstrate a fistula.

 

Colovesical fistula

Video Endoscopic Sequence 2 of 8.

Cystography

Passing the contrast material within the sigmoid

Colovesical fistula: Fistula formation is one of the complications of diverticulitis, accounting for up to 20 percent of surgically treated cases of diverticular disease. Diverticulitis in western countries usually involves the sigmoid colon, and fistulization most frequently arises from this segment. The major types of fistulas are colovesical fistulas (65 percent) and colovaginal fistulas (25 percent), followed by coloenteric and colouterine fistulas.

 

Colovesical fistula secondary to sigmoid diverticulitis

Video Endoscopic Sequence 3 of 8.

Colovesical fistula secondary to sigmoid diverticulitis

Affected patients often give a history of passage of stool and gas via the involved organ. Thus, common symptoms with a colovesical fistula include pneumaturia, dysuria, or irritative symptoms, and fecaluria. Other symptoms occurring in fewer than 50 percent of patients are crampy abdominal pain, diarrhea, hematuria, and passage of urine per rectum.

 

Colovesical fistula secondary to sigmoid diverticulitis

Video Endoscopic Sequence 4 of 8.

Methylene blue was administered with a foley´s catheter into the bladder passing the stain material within the sigmoid.

 

Colonoscopy of diverticular disease

Video Endoscopic Sequence 5 of 8.

Colonoscopy of diverticular disease

Colonoscopy, is not particularly valuable in detecting a fistula, but it is helpful in determining the nature of the bowel disease that caused the fistula and is typically part of the evaluation.

Several reports suggest that laparoscopic resection and reanastomosis of the offending bowel segment is possible as a minimally invasive treatment.

 

 

 

 

Colovesical fistula secondary to sigmoid diverticulitis

Video Endoscopic Sequence 6 of 8.

Colovesical fistula secondary to sigmoid diverticulitis

The incidence of fistulae in patients with diverticular disease, the most common cause of colovesical fistula, is generally accepted to be 2%, although referral centers have reported higher percentages. Only 0.6% of carcinomas of the colon lead to fistula formation.

Colovesical fistulae are more common in males, with a male-to-female ratio of 3:1. The lower incidence in females is thought to be due to interposition of the uterus and adnexa between the bladder and the colon. A 50% previous hysterectomy rate was found among women with colovesical fistulae. In women, other types of fistulae (typically iatrogenic, such as enterovaginal, ureterovaginal, and vesicovaginal) are more common than colovesical fistulae.

 

 

 

 

Colovesical fistula secondary to sigmoid diverticulitis

Video Endoscopic Sequence 7 of 8.

Colovesical fistulae primarily result from diverticular disease. Ileovesical fistulae are most likely associated with Crohn disease. Rectovesical fistulae are more common in the setting of trauma or malignancy. Appendicovesical fistulae tend to be associated with a history of appendicitis.

The hallmark of enterovesicular fistulae may be described as Gouverneur syndrome, namely, suprapubic pain, frequency, dysuria, and tenesmus. Chills and fever are less common, and a colovesical fistula manifesting as sepsis is uncommon. Sepsis has been reported in 70% of patients with urinary outlet obstruction. The fistula may be asymptomatic and is seldom accompanied by dramatic or sudden abdominal symptoms or diarrhea. In most series, patients have been treated for recurrent UTI for 4-12 months before a fistula is diagnosed.

Colovesical fistula secondary to sigmoid diverticulitis

Video Endoscopic Sequence 8 of 8.

Pneumaturia and fecaluria may be intermittent and must be carefully sought in the history. Pneumaturia occurs in approximately 60% of patients but is nonspecific because it can be caused by gas-producing organisms (eg, Clostridium, yeast) in the bladder, particularly in patients with diabetes mellitus (ie, fermentation of diabetic urine) or in those undergoing urinary tract instrumentation. Pneumaturia is more likely to occur in patients with diverticulitis or Crohn disease than in those with cancer. Fecaluria is pathognomonic of a fistula and occurs in approximately 40% of cases. Patients may describe passing vegetable matter in the urine. The flow through the fistula predominantly occurs from the bowel to the bladder. Patients very rarely pass urine from the rectum.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 1 of 15.

Lower gastrointestinal hemorrhage, due a diverticular disease.

An 83 year-old man, retired medical doctor, showing a painless, bleeding by the rectum, He was hospitalize and no hemodynamics changes were observed. His hemoglobin was 9.0 mg/dl.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 2 of 15.

Sequence of images and videos in a case on diverticular hemorrhage.

Diverticular disease is a cause of lower gastrointestinal bleeding. The bleeding stopped spontaneously, the patient was discharged from the hospital 4 days later. Diverticular disease is a common disorder, yet it was not recognized as a pathologic entity until the mid-19th century. Diverticulitis and lower gastrointestinal (GI) bleeding secondary to diverticulosis.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 3 of 15.

Two diverticulae are observed, the video clip displays many blood clots and several diverticulae in different segment of the sigmoid.

Mortality/Morbidity: Mortality and morbidity are relatedto complications of diverticulosis, which are mainlydiverticulitis and lower GI bleeding. These occur in 10-20%of patients with diverticulosis during their lifetime.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 4 of 15.

Currently, diverticulosis remains the most common cause of the lower gastrointestinal bleeding. Diverticulosis of the colon is an acquired disease whose incidence increases with age, peaking after the 6th decade of life. More than 50% of octogenarians have diverticulosis, while only 1 to 2% of people under the age of 30 have evidence of diverticulosis.

 

 

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 5 of 15.

Donut shape blood clot around a diverticula is observed. 

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 6 of 15.

Big diverticula with clot blood remains.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 7 of 15.

The image and the video clip displays many blood clots remains.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 8 of 15.

Same case as described above but the following colonoscopy was performed 3 days after the first one, where the colon is observed more cleared up and the colonoscopy was able to reach the cecum.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 9 of 15.

The image and the video clip display several diverticulae many with blod clots.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 10 of 15.

Sequence of images and videos in a case of lower gastrointestinal bleeding.

Several diverticulae are observed.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 11 of 15.

Rest of of blood clot at one diverticulum.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 12 of 15.

Some diverticulae and small fragment of blood clot are observed at the transverse colon.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 13 of 15.

Angiodysplasia was found at the ascending colon near of the cecum.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 14 of 15.

Several diverticulae are observed with blood remains.

 

Lower gastrointestinal hemorrhage, due a diverticular

Video Endoscopic Sequence 15 of 15.

Endoscope view of the colon affected by diverticular disease.

Many diverticula are seen in the sigmoid.

 

Surgical Resection Specimen

Surgical Resection Specimen

Surgical Resection Specimen, due to a actively bleeding colonic diverticula.

To enlarge the image click here.

Diverticulitis.

Diverticulitis.

Image and the video clip display a diverticulitis of the sigmoid, there have mucopurulent exudate and edema.

Perforating diverticula.

Perforating Diverticula.

The video displays the small diverticula emerge air bubbles that let us to suspect the diverticula is perforated.

 

Diverticula with Fecalith.

Video Endoscopic Sequence 1 of 2.

Diverticula with Fecalith.

Diverticulitis is believed to occur when a hardened piece of stool, undigested food, and bacteria (called a fecalith) becomes lodged in a diverticulum. This blockage interferes with the blood supply to the area, and infection sets in.

 

Diverticula with Fecalith.

Video Endoscopic Sequence 2 of 2.

Diverticulae with Fecaliths.

 

Inespecific Diverticulitis

Video Endoscopic Sequence 1 of 4.

Inespecific Diverticulitis

This 73 year-old male presented 3 days with fever chill and acute left iliac fossa pain, the endoscopic image presents inespecific alterations of the descending colon, patient has diverticulae of the sigmoids.

 

This endoscopic image shows inespecific inflammatory changes in the descending colon

Video Endoscopic Sequence 2 of 4.

This endoscopic image shows inespecific inflammatory changes in the descending colon.

 

Colonoscopy of Inespecific Diverticulitis

Video Endoscopic Sequence 3 of 4.

Colonoscopy of Inespecific Diverticulitis

Recent advances in our understanding of the pathogenesis of diverticular disease of the colon demand a more critical approach to the pathologic, radiologic and clinical distinction between diverticulosis and diverticulitis. In evaluating the rationale and efficacy of newer surgical procedures, full cognizance should be taken of these developments. It is hoped that this will result in a refinement of our indications for surgical operation and provide a solution in our continual quest to apply the right operation to the right patient.

 

Colonoscopy of Inespecific Diverticulitis

Video Endoscopic Sequence 4 of 4.

Colonoscopy of Inespecific Diverticulitis

Methylene blue stain

 

Polyp inside of a diverticula

Video Endoscopic Sequence 1 of 12.

Polyp inside of a diverticula

 

Small polyp protruding from the hole of a colonic diverticulum.

Video Endoscopic Sequence 2 of 12.

Small polyp protruding from the hole of a colonic diverticulum.

 

Polyp inside of a diverticula

Video Endoscopic Sequence 3 of 12.

In order to get the biopsies in small polyps inside of the hole, they are possible to be presented with some difficulties.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 4 of 12.

Colonoscopy of Polyp inside of a diverticula

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 5 of 12.

Colonoscopy of Polyp inside of a diverticula

In addition of the polyps inside of the diverticulum patient
has some areas of diverticulitis
.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 6 of 12.

A follow up colonoscopy it performed and the polyps it is removed, it is observed that the polyps is surrounded with fibrin, possibly as inflammatory reaction to the previous biopsies.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 7 of 12.

With the forceps biopsy, the fibrin layer is removed.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 8 of 12.

The polyps is removed with polypectomy snare.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 9 of 12.

Status post polypectomy there are scanty remnants of the polyp.

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 10 of 12.

Some water is placed in the hole of the diverticula in order
to find air bubbles discarding perforation.

 

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 11 of 12.

To the remnants of the polyp ablation therapy with argon plasma coagulator is being applied.

Argon-plasma coagulation (APC) has been used safely and efficaciously in multiple settings including colon polyp treatment.

 

Colonoscopy of Polyp inside of a diverticula

Video Endoscopic Sequence 12 of 12.

The polyp with basket retriever is extracted.

Small polyp situated just inside the mouth of a diverticulum in the sigmoid

Video Endoscopic Sequence 1 of 2.

Small polyp situated just inside the mouth of a diverticulum in the sigmoid.

 

Small polyp situated just inside the mouth of a diverticulum in the sigmoid.

Video Endoscopic Sequence 2 of 2.

Small polyp situated just inside the mouth of a diverticulum in the sigmoid.

More view of this case

 

Purulent discharge emerging from a diverticulum

Purulent discharge emerging from a diverticulum

52 year-old male, who several years before had been diagnosed with diverticulosis, in a routine colonoscopy is found that one of the diverticula of the sigmoid which when pressed with the scope emerges purulent discharge, had been asymptomatic, management was with antibiotics.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

© 2000 - 2017 gastrointestinalatlas.com
San Salvador, El Salvador | Contact