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I don't need to do full screen or anything. Yeah. All right. We're live now. Um You're welcome to introduce yourself and then start the talk. Hi. My name is uh uh I uh I'm a, I'm a surgeon and uh thank you for uh coming and uh joining us on this uh um teaching session this morning. I know it's a Sunday and a lot of you might not be um uh very, very, very um enthusiastic about it. But thanks for joining in. Anyway. Um So diverticular disease is a really common thing where I am and uh I'll be talking about uh uh pathophysiology. Um What causes diverticular disease? How is it presented and uh mostly uh the complications and the management of the complications. Um So we can uh devise a plan and um eventually an algorithm about uh what to do about diverticular disease. Uh Once you come across it, if there is time uh at the end, then, um I've, I've got a few scans that we could ask people about the management and, you know, just discuss some t as a part of the teaching, is everybody able to hear me? OK. Or am I too loud or um too quiet? You can just type on the messages that you're able to hear me. Uh That would be really great. Right. Thank you. Thank you, Jana. Uh Right. So, um diverticular disease is basically, you know, uh out of mucosal and submucosal there, you know, bowel has got um a cirrhosal layer and then it's got muscularis that's got submucosa and then it's got mucosa. Uh so it's effectively, you know, some defects in the muscularis where the mucosa and the submucosa pouch out, uh generally along the areas where the blood vessels penetrate the muscles. Uh and uh um generally happens because uh there is high uh Luminal pressure uh and some weakness in the wall of the uh wa wall of the, of the bowel. And that kind of over the years builds up uh into causing these uh weak areas where uh the mucosa and sub mucosa can protrude. And as a result of that, uh uh you know, these areas where the, where the divertic form, uh they are really thin and uh uh they have uh this uh ability where they can perforate really easily, either a microperforation or a or a frank big perforation. Um Various other theories, obviously, you know, the most intuitive thing is that there is increased pressure and uh weakness in the wall that causes uh and predisposes to this. And that's probably why you find this diverticulosis most commonly in the sigmoid colon, uh, where the contents are semisolid and, uh, the lumen is quite narrow. Um, and especially, you know, with a bit of low fiber diet, uh, the bowel has to work really hard and generate high pressures to move the, uh, fecal matter alone. Uh, however, uh, you know, uh, we also know that there is some association with changes in, uh, colonic, uh, flora, uh, some changes in the way that bowel might move, resulting in uh spastic uh high pressure contractions. Mm And there is association with uh obesity, uh high BMI smoking and uh nsaids. Um obviously, as we all know that, you know, association um uh causality is not uh not causality, but uh there is strong uh association with that and that gives us some um some, some factors that we can modify in patient to try and uh prevent the diverticulosis or at least um prevent the progression of diverticulosis to complications uh in patients who already have them um um incidents basically, you know, um older people have more diverticulosis. Um 60% have 40 or 60 years and above have uh 40% of the people who will have diverticulosis. And um when you get to 80 it's about uh 60% of the people who will have them. However, if uh people who in the younger age group ie less than 50 years have them, then it is possible it, it's more likely that they get more uh symptomatic uh um uh diverticular problems from their diverticulosis. Uh and, and, and they can have multiple episodes as well. Incidence is rising. Um Again, you know, we talk about low fiber diet and high fiber diet but it has epidemiological association. Uh but obviously causation is not uh not proved, but we do know that uh mm in populations where there is uh generally a high vegetable content and high fiber diet. Um diverticulosis is not uh not, not very common. I um how does uh diver, how do diverticulosis uh present? Um So um vast majority of them are asymptomatic. Um And really, you know, we generally never find out about it unless we do a CT scan which gives us a characteristic picture of diverticulosis or a colonoscopy where a Luminal view can be obtained and we find that somebody has diverticulosis um and the vast majority of them don't ever um need any intervention or don't ever have any uh symptoms related to diverticulosis. Um We talk about uh uh primary prevention ie high fiber diet, giving up uh uh smoking, uh avoiding in acids and um and uh and uh being more active um uh in, in, in lifestyle. Um But again, you know, uh whether uh what is, what is the actual benefit uh or that we, we get uh from these interventions may or may not be very proven and hence, they are not very focused upon. Now, diverticulosis can cause uh uh problems in a small minority of patients. The first one is diverticulitis, which is infl inflammation or infection around the divertic, uh possibly because of stool. Um and uh they can be uh and that's called diverticulitis, which can be simple or which can be complicated with an abscess or a proliferation. Um repeated episodes of uh diverticulitis uh can cause uh uh some narrowing uh and fibrosis in a particular area where the repeated inflammation happens And that can result in uh scar formation, narrowing, and therefore proximal obstruction in the large bowel. Uh sometimes the repeated inflammation can track into surrounding structures and cause crystallization. Um And then obviously, there is this uh risk that uh uh because uh the divertic are thin blood vessels going into them, uh then they can erode and cause some bleeding. Mhm So, about a quarter of people with diverticulosis may have diverticulitis. Um and about a quarter of those patients who have diverticulitis will have some complications and generally, you know, most complications are quite minor complications and, and they can be treated um without any significant operations. Um As I mentioned that uh longstanding or recurrent diverticulitis, it can cause fibrosis and thickening and therefore stiffness of the large bowel is cross linkage of um uh of connective tissue, thickening of the uh circular muscles and uh longitudinal muscles uh which are the tia uh coli and therefore, the bowel becomes quite thick fibrosed and uh you know, the compliance of the bowel decreases and that obviously can cause further increase in pressure. Uh because the bowel is not able to accommodate stool coming in that easily uh as the compliance has gone. Um So that can further predispose to bigger um uh divertic forming. Um, what does that do for us? Well, as I said that about a quarter of them will go on to um uh develop diverticulitis or complications. But, um, it does problems for us in other ways as well. So for example, if we are trying to do a colonoscopy and we do, we go through that uh segment, the area is quite narrow, it's not pliable and uh it makes it harder for the scope to pass through them. And uh also uh sometimes if the vertically are really big, um they can present as a false lumen. And um you know, one of the rare complication from that would be that uh you could try and go through that uh uh thin area and the diverticula may cause a perforation. And also when we are resecting uh the bowel for any other reason. So, for example, for cancer, um you don't want to do an anastomosis through a diverticulum because that will um be a area of weakness and therefore, uh predisposed to uh leakages of the anastomosis. And therefore, you know, it, it, it presents some challenges. If somebody's got uh about riddled with the diverticulosis, then uh you'd uh you know, you need to find a clean area or have to improvise. So you don't actually take your stitches or your stales uh through the uh through the um through the affected area. Um The other um issue with diverticulosis uh and the complication of diverticulitis, especially if it's complicated with an abscess is that it's hard to do these things happen over um over, over a period of time and they probably happened before in some clinical way. So by the time the patient comes uh to us, and we are planning to do an operation or having to do an operation for a complication. It's hard to distinguish uh clinically whether it's uh cancer or it's a diverticular abscess and diverticulitis. And uh therefore, if there is any uh reasonable doubt or that it could be a cancer um which can turn out in a minority of uh diverticular resections as a surprise. Uh We should do an oncological resection. So take the lymph nodes uh um draining that ba in uh and do a higher up, which probably means that we'd have to do a resect a bigger segment, a longer segment of the bowel. Uh Then we would uh normally just for the perforation if we were uh confident that it was just uh diverticular um complication. Um How do we diagnose uh if uh if, if there is some complication, the white cells and crp will be elevated and sometimes if the patients have got septicemia, uh then the renal function can be affected as well. Um uh We can do imaging. CT is the mainstay of uh imaging. Almost all people in um where, where, where I am would get a CT scan who came and uh had pain in the left eyelid for sure. And uh and, and some raised inflammatory markers giving the impression of uh diverticulosis. Um you know, uh in, in in other settings, people can u people have used ultrasound, which can in expert hands give some good indication about uh diverticulosis, the thickness of the bowel wall um and any collections around it. Um But, but I don't think we use it here. Um where wherever uh gastrograph and enema again was used historically, but doesn't serve any purpose. Now, it's not, it's not used for. Um it could be, it could be used if there is nothing else available to give an idea of uh of perforation, active perforation or no active perforation uh versus the extent of diverticulosis. But um it's, it's not used anymore. An MRI would give a better uh definition of the bowel, uh the fibrosis scarring uh and the extent of the of the disease and could also indicate about uh the collection around it. Uh But MRI is cumbersome hard to get, it's not that much available and you don't want to stick an m an unwell patient uh into a, an MRI scanner which takes much longer than a CT scanner. And uh you know, involves having the patient to be uh in uh that uh uh tunnel, the scanner for um up to half an hour and generally not used in, in acute setting. No, um when we do investigation and we treat um some complication of uh diverticulosis, um we almost always uh consider uh follow up a Luminal imaging, which is uh you know, either a colonoscopy or a CT colon. Now that CT colon with the uh full bowel prep and um you know, rectal uh injection of uh air and inflation is uh almost as good uh diagnostically as uh CT uh as a as a formal colonoscopy. Uh We can consider that as well. However, um mm followup, Luminal imaging uh was routinely done with everybody who presented with the diverticulitis uh episode uh getting a colonoscope uh in about six weeks time. Uh But people have looked at that and found that that is uh not supported by evidence in uncomplicated uh diverticulitis ie uh when there is no abscess around uh or perforation uh around the inflamed diverticula. When it's mild, there are no other symptoms uh related to the bowel in a young patient. Uh you don't really need um uh a view. However, if there has been complicated diverticulitis, the bowel is thickened, there is a peri diverticular abscess that has been treated with antibiotics. If there is a suggestion of thickening of the bowel, as I said, or a mass, uh which could easily represent uh inflamed diverticulum and repeated infections there with fibrosis. But uh uh could also represent a cancer if there are some lymph nodes in the mm the meal colon or uh if there is multifocal inflammation or even inflammation without diverticulosis, um or if there is a preexisting reason. Um I for example, if there is um uh if, if there is an occult uh of blood um detected on the stool and the patient was being considered for a colonoscopy. Anyway, uh we go on and do that uh colonoscopy. Um When I mentioned inflammation without diverticulosis, uh what I'm uh you know, at that point, I'm looking for an inflammatory condition of the bowel for like uh er colitis or Crohn's disease, um which is, which can, which can be there and, you know, especially in uh elderly patients, it can be the second peak of uh IBD. But uh it could also uh be related to some infections um which, which are generally short lived less than uh six weeks and settle spontaneously. But if they don't settle, then we might need to get uh a colonoscopy and biopsies and some uh to confirm the diagnosis. Um they all used to be done in about six weeks time and if there was a significant risk, uh significant rise in uh inflammatory markers and uh it looked like that there is uh some uh perforation. Uh then my personal practice and a lot of people would call the patient back to their clinic in a few weeks, time, four weeks to six weeks', time, see how they are doing. And if they are completely settled clinically, um then we go on and do request a colonoscopy to take in a few weeks. And uh the reason of this delay was that uh mm the impression was that if uh an area is uh already got only mucosa and submucosa cover on it, uh, and it's a weak area and we strip a scope in and blow it up with a lot of air, then it can perforate. Uh, but that is not born with the evidence. And uh if we need to confirm our diagnosis or for any other reason, then, uh uh then, uh um then no, um you know, you can do a colonoscopy uh in, in, in one or two weeks. Uh But, you know, try, uh what we try and do is to do a gentle in circulation. Um I'm not entirely sure whether there is any role of fecal cal protecting because, you know, fecal C protecting would, uh be, uh um, you know, it would just pick up some inflammation somewhere in the bowel. And if it's diverticulitis, you know, you could potentially get um, some rise in fecal protectant, which may not be very high. Uh But it just doesn't help. Um uh really, uh because we know that the inflammation is there. Now, uh, uh the first thing with these diverticulitis. Um uh The first thing with the diverticulitis, you know, the mildest bit is uncomplicated, acute diverticulitis and this is a systemically. Uh Well, patient uh left lower quad pain, uh some mild tenderness, some peritonism young patients could be quite, uh you know, uh represent quite a bit of guarding. Uh they could have quite a bit of guarding and tenderness but may not actually represent any perforation. And uh these patients uh with minimal rise in white cells and crp uh some tenderness and the pain uh who are systemically well, could be managed as an outpatient with analgesia and uh um and, and, and with or without antibiotics. Now, in uncomplicated a simple acute diverticulitis, the rule of antibiotics is um is, is a bit controversial uh because uh the initial stages of this inflammation have been postulated to be uh immune mediated as opposed to infective. And uh the uh the recent trials, uh some of them which have been reported and some of them which are ongoing have really uh reported no difference in people who got antibiotics and who did not get antibiotics. One of the trials looked at inpatients and um and the other one looked at uh uh as an outpatient um uh type of situation and they really didn't find a lot of difference or at least not statistically, statistically significant difference between people who got antibiotics and who did not get antibiotics. But again, I have to stress that this is acute uncomplicated diverticulitis. If there is any complication in the diverticulitis, then um for resulting from diverticulitis, then antibiotics would have to be given. Uh Generally, I would give a triple therapy covering uh gram. Uh This, you know, the recommendation is to cover gram negative and anaerobes. Um But uh I would, I would uh generally use triple therapy to cover all cases. Um There are a lot of uh uh different methods of uh classification um on how to, how to classify um the severity of diverticulitis. And these classification generally didn't remember these uh classification generally deal with complications. So, if uh complicated diverticulitis, so if it's simple, acute, this is outside of those classifications. And uh once the patient has had some problems, um for example, um you know, peri diverticular abscess or an abscess, which is uh distant from uh just the pericolonic area uh or purine peritonitis. Uh four quadrant, purulent peritonitis which just pus in the abdomen or four quadrant, uh um fecal peritonitis with stool, um actually lying about in the uh various parts of the abdomen. Um So they, they all deal with complicated and the most common one that uh we generally tend to use is classification. It's really simple, straightforward and gives us a nice actionable points of view. Uh Well, actionable stages which uh we, we, you know, which we treat differently. So this actually classification has an impact of how we, how we treat the patient. Um As I, as I said, that, you know, you can have a mild diverticulitis um confined to uh with the abscess, confined to uh pericolonic or peri diverticular area. Um Then uh you can have an abscess which is uh distant uh uh in the pelvis, for example, which is the most common site. Uh you can have for per peritonitis and uh and fecal peritonitis. So, no, I don't think uh any uh you know, giving high fiber or low fiber um is, is, is, is of any uh significant consequences. I generally advise patients to just carry on with their regular diet. Um but would recommend high fiber once the inflammation has completely uh settled down. Uh but it's not shown to have any significant uh uh difference going forward. Um looking at uh as, as you know, most of the patients with uh uh who come with acute diverticulitis in the uh to the hospital and get admitted would get a CT scan. Uh So there is uh obviously, you know, as you'd expect somebody has developed uh uh CT classification, which is that uh if the wall is more than five millimeters, um then it's mild diverticulitis. And um if inflammation is localized to that area and if there is anything else, anything more severe than that, then that would be severe diverticulitis. Um um going by HS classification, which is what I tend to use in my clinical practice is that it could be a smaller, uh, mali, uh, localized to the peri, uh, colic area. There could be a small, um, abscess. Um, ideally if there's anything, up to five centimeters, I would, uh, um, anything, uh, up to two centimeters, I would treat it with, uh, just, uh IV antibiotics. Uh, and if the patient is, well, I would give, uh, switch that IV antibiotic, uh, regimen to, uh, oral in, uh, 48 hours. And then uh if they are improving, then uh send them home. And uh if uh it is five centimeters, then I would consider, and you're not responding, then I would consider um uh drainage uh with the radiological guidance. Uh Second uh mm level would be inch two where there's a larger abscess. I, you know, uh most logically going into the pelvis. Although I have to say that we focus only on sigmoid diverticulitis because that's the most common. But diverticulitis can happen in right colon. It can happen in transverse colon and has happened. And uh that results in a bit of atypical um uh presentation. You know, where patients don't get left eye fossa pain, they can have central abdominal pain, they have upper abdominal pain, they have got rightsided abdominal pain and sometimes uh and, and, and, you know, the CT scan gives us the answer in those cases. And sometimes the sigmoid is very loopy with a lot of redundant uh mesocolon. And therefore, uh the peri diverticular abscess in the sigmoid colon, instead of presenting as pain in the left, a fossa will present as pain and fullness in the right a fossa. Uh So again, you know, um uh the importance of uh of, of imaging. So these pelvic excesses uh I trying to treat with the IV antibiotics and IR drainage once the drainage has been done in the past, has been taken out, I will uh give them uh convert these antibiotics to tablets. And if the patient can manage the drain to send them home and then come back in a week's time, uh to assess further with possible further imaging to check the status of the um uh check the status of the abscess and uh see what their in markers are doing in uh henches three, which uh gives us uh purulent peritonitis. It means that there is a small perforation where uh bacteria have leaked out cause lots of uh uh reaction and infection throughout the four quadrants of the peritoneal cavity. Um These kind of patients would uh require IV antibiotics, of course. Uh and uh they have uh various modalities. Um obviously, the standard modality for uh treatment, which is the safest practice routinely and traditionally, has been the Hartman's procedure where we tend to resect the disease uh segment and uh and then staple off the distal end and bring the proximal end of the colon out as a colostomy. Now, remember when we are doing this operation, we don't really need to go to a healthy area. Uh ie uh diverticula diverticulum free area to bring that colostomy out patients. Uh uh you know, some patients could have divertic all uh throughout their uh bowels. Uh, and we only need to, uh, remove the perforated bit and the perforated bit of the colon and the bit that is inflamed and infected, which is represented peroperatively by thickening and induration. Uh Once we are into a softer and pliable area, then that area could be brought out as a stroma. And uh similarly distally in the, in the rectum, we don't really need to take all of the sigmoid and go to the rectum. Uh We just need to take the least uh you know, go to a healthy area and because a lot of vertically perforate into the mesentary uh and then go across into the rest of the abdomen, we, I tend to palpate the entry as well. And if there is any thickening or inflammation or a bit of pus oozing from the mesentary, I tend to take that part out um which can be slightly tricky because uh uh the blood supply, if you remember from an um of the mm proximal rectum and distal sigmoid is all coming from uh inferior mesenteric artery. And if we take out a lot of entry, we could uh compromise the blood supply that goes into the rectal stump or the stump of the sigmoid that we are closing and uh that could result in a blowout of or disruption of the staple line or the suture line that we do there. Um And therefore, you know, with these kinds of resection resections, unless we are sure we un unless we are, you know, thinking of a cancer there, we would tend to uh preserve the entry as much as uh as possible. So the blood supply goes and um during your uh during the operation, we should assess the blood supply of the staple gents. Um quite um quite carefully to make sure that we are not leaving any relatively ischemic, uh um bit of the bowel in which can cause huge problems later on. Um No. Uh this was the standard uh treatment for um for quadrant peritonitis. But for purulent peri uh for, for diverticulitis and perforation, but for purulent peritonitis, um uh in increasingly uh what has been used as a laparoscopic washout. Uh So laparoscop lavage is a very um valid indication. It prevents a stoma, it prevents dissections and um can tide the patient over until they heal, uh an infection is taken care of. But this laparoscopic washout has to be um done by somebody who's experienced in this uh um kind of a procedure uh because as um most patients have developed it over a few days and when they come to you and when you're doing the operation, uh when you put the scope in there is a lot of fibrin um around in the peritoneal cavity and that kind of, um especially the small bowel loops are quite stuck together. So, and from just looking at the, the valve through the camera, it looks like that we have washed everything in the paracolic gutters in the pelvis, uh uh behind the omentum um in the upper abdomen if it was up as far as um uh subic areas. Uh but uh generally, um, people may not be able to get all the interloop abscesses between small bowels. So it has to be a painstaking. It, it's not a quick thing. It has to be a painstaking, slow, uh meticulous uh uh separation of small bowel loops, find if there is any pus behind them and then clean that out thoroughly and that would work. Uh But if we, we just cleaned out all the visible pus left interloop abscesses between the small bowel loops back, patient will not get well, might eventually need to be taken to theater back again and again. Um So we, we do that, we may have to repeat another washout or uh patient may eventually uh end up getting a Hartman's procedure. However, um, it's, uh it's, it's, uh it's, it's a valid method and it works in a lot of cases preventing um a bowel resection. However, it is not to be used if the patient is in septic shock or fails to improve after antibiotics. Uh patient is immunocompromised. Um, patient is frail or if, uh even if the purulent peritonitis and no stool uh in the peritoneal cavity, if there is a visible wall defect, uh chronic wall defect, that we can see, um we should take that bit out. Uh because if not, now, then later on stool will um uh come out of that. And again, you know, this, uh there is, uh there is now, uh more and more tendency with the laparoscopic surgery to try and uh avoid stoma due uh primary anastomosis, which is uh been recently studied. And um uh you know, uh a left sided colonic resection is uh generally expected to have a leak rate of less than uh 5% uh with the resection and primary anastomosis in um in a primary in, in, in, in diverticulitis, acute diverticulitis and per peritonitis. Um The leak rates of about 6% have been demonstrated in smaller series. So, if the patient is um otherwise physiologically well, they are not on strong minor probes, for example, and they are not in septic shock, uh then uh there may be a case to do a dissection and primary anastomosis and somebody's got the expertise to do it laparoscopically. Um And these patients do well. Um some surgeons will cover them with uh diverting ileostomy in the distal ileum or terminal ilium. And some people will uh leave it as such because remember this is a non prepared valve. And if the, if the, if, if the anastomosis leaks, then you put a stool in your uh peritoneal cavity and pelvis. Um So it may be worthwhile considering, uh covering iost toy. Um But if, uh, the patient is really well, then we could just do a primary anastomosis and, uh, and, and, and then patient would be spared all the uh comorbidities of a stoma and then a further procedure, um, inches four where stool has leaked out, there is uh lumps of stool, uh sitting in the peritoneal cavity, we obviously give antibiotics. Um Heart's procedure is the mainstay of the treatment. Uh But again, you know, uh if the patient is uh is, is, is well, when I say, well, I mean, relatively well, uh a resection and primary anastomosis can be uh can be considered. Um Do we do elective resection for diverticular disease uh for patients who have had acute diverticulitis. Um I guess, um traditionally, as in several decades ago, it used to be thought of as a preventive operation that somebody's got acute diverticulitis. Uh one or two episodes and they keep coming in then to prevent the disease from progressing uh and to prevent further complications. Um one tended to do an elective resection and anastomosis uh as if it was sigmoid, then a sigmoid colectomy. However, now, large epidemiological studies have shown that uh mm a recurrence risk for an acute diverticulitis is 2% per year. Uh and the risk of emergency surgery is really minute. So, you know, most of the guidelines, uh don't recommend any elective resection uh for uh people who have had one or two episodes of acute diverticulitis. However, and uh we can make uh decisions for elective resections in individualized patients, especially people under 50 who've had more than four episodes, um and keep on getting further episodes of diverticulitis. Uh people who have had what we call um ongoing diverticulitis or smoldering diverticulitis who keep um getting a persistent level of pain and discomfort, excuse me, in the left fossa, the inflammatory markers remain up. Um And they tend to develop an inflammatory mass in the left fossa which can sometimes be palpable as well. Uh People who have had a fistula or have uh developed a stricture. So this can, they can be considered for elective resection. And uh you know, uh uh people, you know, especially uh the subset where they have uh uh recurrent episodes in younger patients. Uh They, they should be aware that uh they can end up uh getting a stoma. If for example, peroperative, it's not safe to um anastomose. Um mm So remember I said that we are not taking out all the divertic that are there in the bowel because some people will have pan colonic diverticulitis, diverticulosis. So they could have uh recurrent diverticulitis in some other part of the bowel. Um either in preexisting divertic or divertic that they develop later on So they should be aware that aware of that, that an operation doesn't necessarily cure them of the risk of getting diverticulitis. And uh once we have had a resection of the bowel, uh mostly the left side of the bowel, uh then they can be functional symptoms like urgency, loose motions, even constipation. Um and some episodes of incontinence because of the shorter transit times. Um So, and, and, and they have to be aware that their bowel function will never be uh the same as that was before they had their operation. So there is a space, uh there is a place for elective resection but um you know, it has to be carefully considered and um you know, we don't just offer it to everybody. Um The other complication from a vertically will be bleeding and generally, uh people get either inflammation or bleeder bleeding. Um but generally not both at the same time, uh say generally, but sometimes you come across an outpatient with what can happen. But as, as, as a general rule, um people come with either bleeding and soft abdomen or diverticulitis and no bleeding. Um The good news about bleeding from uh mm divertic is that this majority stop spontaneously. You just have to keep them uh in the hospital, um monitor their hemoglobin um and just let them eat and drink and uh the bleeding tends to stop. We do tend to um you know, uh risk stratify them with the shock index and uh and, and score. Um but uh you know, if, if the patient is well and they're not actively hosing out blood from the uh bottom end, uh the bleeding will tend to stop, especially the lower gi bleeding and more specifically the diverticular bleed. Um Obviously, anybody with the bleeding comes in, we have to uh do resuscitation and correct the coagulopathy. Uh if the hemoglobin drop significantly replace uh blood products um with the uh hemoglobin. Uh you know, so, so if somebody is getting acute blood loss, we know that hematocrit or hemoglobin is practically useless as an index of how much blood they have lost because that's always uh behind uh what the actual situation is likely to be. Uh So we um uh replace blood products based on their clinical picture. But um generally if there is a, a hemodynamically stable patient and there has been uh some, some, some loss of hemoglobin over a few days and we keep a threshold of about 70 for noncardiac patient and about 80 for cardiac patients. Treatment for bleeding is, as I said, expectant to start with. But if we are not able to manage with expectant treatment, then endoscopic treatment is the mainstay followed by angio embolization surgery. Um I would tend to stay away from as much as possible, only use it as a last resort because when you're operating, um unless uh you had some intervention uh radiology support and they have managed to localize uh the site of bleeding, um with the hook with the wire that goes up the vessel and goes into that. Um It's hard to uh actually localize the area of bleeding. Um And therefore you might end up resecting, one might end, end up resecting uh the wrong bit of power. Uh And at the end of operation, patient would still be bleeding. Um So, so, you know, surgery is not really uh the first line I'd use here uh with endoscopic treatment, um that's really good. Um Endoscopic treatment works. And um it is effective and it does not carry the risk of uh causing ischemia and necrosis to the bowel uh resulting in a requirement for an immediate uh resection in the next few days. Uh that angio embolization carries. So, ideally, endoscopic treatment should be done with bowel preparation uh because otherwise you don't tend to see anything blood absorbs light inside the lumen and everything looks black. Uh It should be done within 24 hours because the stigmata of bleeding are still there at that time. Uh If you do it later than that, uh then it is possible uh that the bleeding uh that the point which was bleeding may have uh you know, sort of regressed, it's not that clear anymore. Uh And therefore, it's easy to miss. Um initially we as with all bleeding, uh we injected rin injections and then uh we can use other modalities like uh buzzing that area, uh band ligation or marking with band ligation. Uh But the most active thing is uh through the scope clips, that's what this s means. Uh So through the scope clips is uh what we do is that uh we can, if we can see a blood vessel going into that uh diverticula, then we uh try and put a clip on to that if we can uh um if we can uh invert the diverticulum. So with the grasper uh grasping forceps, we can uh put it carefully in the diverticulum and pull it out to invert it. Um Then we can uh um you know, um uh band it with a, a rubber band uh or uh if we can't invert it, then what we do is that we go uh to the mouth of the diverticulum where it is bleeding. So, somewhere about here, for example, or uh here if you can see my um my, my cursor uh and then uh mm and, and then put the clip so the mouth of the diverticulum is closed. Uh And then we can uh do two or three clips. So uh the diverticulum, even if it's bleeding inside will have a tempo, not there and the blood will not be freely flowing into the p and that gently stops the bleeding. So it's, it's, it's, it's a good uh uh method to use. It works really well, but it needs specific expertise. And one, if one is not competent to do that, then you should stay away from that kind of stuff. Um Other bits uh complications can be that uh chronic inflammation, repeated inflammation uh can result in um uh eroding of that uh fistula into surrounding structures. The most common being um the urinary bladder um that presents with uh recurrent uti is most commonly if it is a small fistula, if it is a tiny hole. Uh but if it's a big hole, then patient can be peeing uh stool and uh stool colored and stool smelling urine. And patient can have hematuria who can develop arthritis. Um It's basically urine tract infections uh along with uh some uh some, some air with the urine. Um and some stool with the urine ct shows sometimes shows that uh track and um and, and generally has air in the urinary bladder without um there having been any history of instrumentation. So you put a foley catheter or do a cystoscopy or any kind of instrumentation in the bladder through the urethra, then you'd introduce air. So in that case, the air is not that uh exciting, but uh if you've not done any of those things and there is air on a CT scan, um somebody in an outpatient setting, then, you know, uh that would indicate a fistula important to do a colonoscopy and a cystoscopy to see the lumens on both sides. Uh because um you know, while diverticulum, uh can cau a diverticulum can cause a fistula cancer can also cause a fistula either in the bladder or in the bowel. So we have to visualize the Luminal views on both sides. How do we treat that patient? So, treat, I mean, depends on how fit or unfit the patient is. The patient is very comorbid, they're, you know, not fit for any kind of uh aggressive treatment. Um Then what we tend to do is to do occasional bladder lavage, uh, to prevent, uh urinary sepsis and, uh, keep them on low dose long term, uh, antibiotics like ciprofloxacin. Um, II, suppose this is the minimal way to try and avoid recurrent episodes of sepsis. And, um, and, and, and that's generally it, uh, you'd expect that with the, um, with the fistula, uh, you know, one can do, uh, nail by mouth and TPN and bowel rest and, um, you know, all sorts of things, but if the patient is not well enough, um, or is hugely comorbid and they are elderly and they've got multiple comorbidities, limited mobility. You don't really want to, uh, subject such a patient to, uh, an aggressive treatment because ultimately, uh, trying to, uh, give TPN for a few weeks with nil by mouth is going to take its own, um, cause its own for morbidities. Um, so this is, uh, the least thing that we can do in an unwell patient, uh, in, in, in a frail patient somebody who's fit for uh surgery who's otherwise fit and well, uh gets a fistula, uh younger patient, uh no comorbidities and we do, um, do do a resection. The resection can be open or laparoscopic. Obviously, with all that ongoing inflammation and fistula, there is a laparoscopic surgery is quite challenging. Um, but uh it is, it is doable because most of these fistulas tend to be at the dome of the bladder quite easily uh approach. Um What we do is that we um find that uh removal of the adhesions, find the fistula, cut it out, uh freshen the edge of the, freshen the edge of the bladder and repair it and uh resect a bit of the uh sigmoid and then anastomose it. And generally, that does the trick. Uh these patients do really well because there's no ongoing sepsis. If there is any collection in the fistula tract, then that obviously needs to be trained. Uh One thing to be aware of is that you want to keep the foley for two weeks, do a cystogram to confirm healing of the bladder before removing because this is generally intraperitoneal. Uh And you don't want an intraperitoneal hole in the bladder, um you know, or leak in the of urine in the bladder. Um So therefore, we have to confirm that uh before removing, removing the catheter, right. Oh fistulization can happen in other structures as well. And you know, everything around that. Um You look at it in um uh um, yes. Yes, we do give uh prophylactic anti anti antibiotics. And that's true for all, uh gi uh you know, bowel surgery. If you're opening a, a cavity with, uh uh with, uh, with uh bacteria in it, then you have to give. Absolutely, you have to give prophylactic antibiotics. Uh So, fertilization can happen. Skin ureter, vagina, fallopian tubes, uterus. And, um, and this was the, you know, um this is this, this is retroperitoneum and, and, and these are treated more or less in the same way. You know, if the structure is resectable, then we just resect it and get it out. Uh But if the structure is not resectable. So for example, vagina or um uh sometimes uterus retroperitoneum, um we um tend to uh do a heart man if the patient is uh septic and if the patient is not septic and they will then to uh try and do a resection and primary anastomosis. Um And II know that just last week, we did a patient who had uh facil into their so uh facia and had to presented as a so abscess and we tried to keep him conservatively on um with proximal uh ileostomy uh did not work. His abscess kept being fed by the uh by the fistula and uh a few admissions in and out of the hospital antibiotics. And we finally did a hard for him last week. Um and hoping that he's doing well. Um, he's, he's been well so far but we, we need to see another week or two before. Um, and we know for sure that it settled down. No. Uh, no, I think the last comp complication would be obstruction. Um, obstruction is generally distal, large bowel obstruction because sigmoid is the most common one. But, uh, you know, and therefore vomiting may not be a prominent feature, um, because it takes a long time for the large bowel to fill and the small bowel to fill and the stomach to fill and large bowel, uh, you know, you can have constipation is the most prominent feature, uh, and abdominal distension but not, uh generally, no vomiting is not, uh that prominent, um for light bulb obstruction. Uh we have to be, um, looking at a few factors. Uh For example, like, uh if a patient has got an competent and incompetent ileocecal valve, if there is an incompetent ileocecal valve, that's good because uh, then the patient does not have a closed loop obstruction between the stricture, for example, in the sigmoid and between the ileocecal valve, uh which it can cause quite a lot of distension and, uh, you know, cecum being the most vulnerable can give away, um, and perforate. Uh And if the patient is, uh if the patient systemically well and well or, um, again, if the abdomen is tender or non tender in markers, uh are normal or elevated, um, and if the patient is well and there is a competent, uh, unwell, sorry, if the patient is unwell and there is on competent cecal valve, then, uh, we do surgery quite quickly. Uh, the reason is we don't want to blow out of the cecum. And because if that happens, then we are committed to, uh, a subtotal colectomy. Mm, which is a much bigger operation. More b uh, patient loses more bowel. So we try and do quickly. One option would be to do a proximal diversion. We can do an ileostomy or a colostomy. And surprisingly, even with the competent ial valve, ileostomy works really well in diverting and deflating the bowel. And then we can uh um you know, once the patient is well, we can consider a resection or, or any, any other treatment. Um You can do a transverse colostomy as well. Um But again, you know, colostomies tend to have their own problems in terms of prolapse and management. Um And uh and, and, and, and therefore, you know, a lot of people would just favor an alloy or a colostomy in this situation. Um What we can also do um ideally so, so we can do a hearts, we can do a proximal diversion. But what ideally, we, we, we should do um if the patient allows, if the patient is not very unwell is to do a primary uh segmental resection of the strictured uh area, do an on lavage to clear the distended proximal bowel and do a primary anastomosis. And the patients generally do really well. If the ont lavage has been done, the patient is well and there is competent ileocecal. Uh sorry if the patient is well, I should have put her incompetent IUC valve. Uh which means that the bowel can be de bowel continues to decompress into the small bowel. Uh We can start with the drip and suck. Uh We can go for a higher heart man resection and as in all cases, uh which is a safe and effective uh, time tested method. Um, but we can do, uh, we've got two other options. One is the primary section on lavage and uh anastomosis. And, you know, on T lavage is, um, ii don't know if a lot of people do that or not, but it's not as tricky as it sounds. It can be a bit messy if you lose control of the, uh, of the, of the proximal bowel in the stool coming in. Uh, but it can be easily uh done with some, uh, sterilized, uh, you know, ventilated tubings. Um And, uh, and, and it gives really good results. Um There are obviously, um, propriety systems for it, uh which may or may not be available uh in any given hospital. But, uh uh you know, uh with, with, on one can do a primary secondary anastomosis. Sometimes one can consider a temporizing stent to let the, um, obstruction settle down and uh then uh and then, and then, then do the uh the resection. However, um stents are generally employed for malignant obstructions. We do really well because there is a lot of the tumor gives a lot of uh strong purchase and stops complications from the uh from the stent from happening. Whereas uh for benign conditions, if we stent uh one, you know, uh in a younger patient and the stent stays for longer. Um And second, uh the purchase of that stent, the stability of that stent is not that much. So therefore, they can cause perforation in the valve and they can cause they can cause migration. Uh So generally, uh stents are avoided um in benign conditions. But uh you know, if there is no other option and uh this is an easy thing to do. You can stent the patient, uh let them move their bowels for a few days and then go on and do the uh go, go on and do the resection uh with or without a bowel prep. So the treatment algorithm basically uncomplicated diverticulitis. Um As as you can see, you know, this is uncomplicated. The second column is compli chronic uh complicated. And the third one is acutely complicated. Um they have different presentations but everybody gets a CT scan. Uh So a CT scan, uh once you get the CT scan, you define the extent of the disease. If it is simple uh diverticulitis, we can just, uh, send patient home with or without antibiotics depending on how their inflammatory markers and their tenderness is doing. We could suggest some high fiber diet, but I would tend to give high fiber diet after the episode has resolved. And, uh, that would be a suggestion and I would want them to just, you know, completely push high fiber diet in their, um, in the, in the, in the, as part of their diet mix. We can also uh give some mesalazine and uh but, but, but II, II, don't think that's routinely used uh for um acute, you know, we have said that was depending on what classification it is. We could do per antibiotics alone, uh percutaneous uh drainage and antibiotics or surgery. No. Uh we've got a few minutes and I was um going to say that if uh we can, you know, look at, um, you know, about three or four of these uh cases with scans. So this case, one is a 48 year old male, lower abdominal pain, uh the temperature of 38.8 and some lower abdominal clotting and that the CT scan. Um if um if everybody can see uh see the CT scan can they type uh see what they think should be done as a treatment for this patient. Mm. So where the arrows point? That's where the abscess is. Uh this uh if you can see my cursor. Yeah, that's a pericolic abscess and uh, it does seem to be that it is pointing quite, uh, you know, towards the skin and, uh, going to the rectus sheath area may maybe in the process of, uh, going through that and, you know, sort of pointing under the skin. Uh So what should we do with them with, with such a patient? Uh Remember it's a young patient. Um, so I'd expect that there are probably not much comorbidity, uh, um attached and um, his heart rate is 100 and temperature is sort of, you know, in the febrile range. Um There is some guarding and rigidity but it could be related to uh related to just this abcess pointing so close to the skin. If the same abcess was deep buried in the pelvis, then uh uh then, then it will be less tender. Yeah. So, II think, I think that's, that's right. Most of you've got that, uh quite, uh, quite nicely what we do in this case, it's a fairly big abcess. Uh and about more, more than five centimeters. So I ask a friend, the radiologist to put a radiological guided drainage, give the patient antibiotics. Um And then wait for this uh, abscess to settle down. I would, uh, you know, um, uh a, a laparoscopic drainage would actually be um quite useful if it was not confined to one area which was drainable. And as you can, uh, if it was a four quadrant thing, then yes, I would go for laparoscopic drainage but uh for this particular abscess and uh you know, percutaneous drainage might surface because as you can see just around that abscess, there is a very well lighted uh wall around it which shows that it is uh localized and has got a, uh got, got a wall around it which is localized aces and therefore a drainage uh might work short of an operation. Right. Yeah. Yeah. Yeah. Mm Right. So, next one is a 72 year old male, left eye fossa pain and tenderness and systemically well. And that's the CT scan um and incidentally, you know, when you um yeah, drainage and Yeah, absolutely. Uh So, uh for example, uh we, when we look at the CT scan of a normal patient with the diverticular disease and not diverticulitis, we see these small uh bits of air in the wall of the diverticulum and they continue along the wall of the diverticulum as you can see here just uh be close to the rectum and just above in the descending colon. Uh So that's the, you know, classic picture of what the diverticulosis will present like. And we got where the arrow um is pointing. Uh you know, there is a bit of dizziness and fat straining that indicates quite a lot of inflammation in a 72 year old with some left fossa pain and tenderness systemically. Well, um um So, um I'd imagine that with that inflammation, you know, this would represent simple diverticulitis with no peri diverticular abscess uh can be seen on this view anyway. Uh, so this is a patient, uh, who's got uncomplicated, uh diverticulitis and uh such, such a patient, I suppose. Um, what would we do with that? Uh, uh, such, such a patient? Mm. Yes. So, that's, that's right. Uh, I would, um, II think, um, that's what I would do. Give him antibiotics if his white cells and CRP are not very high, I could potentially send him home as well. But, you know, we start with IV antibiotics if it's, um, if it's, uh, white cells and CRP are uh markedly elevated, but if they are something like 12, uh white cells and uh CRP of 35 I could even give him some oral antibiotics and can send home and if it is a younger patient who's otherwise fit and, well, I will give him some worsening advice that if pain gets worse or, uh, you get really unwell or tenderness or starts spiking fever, um, then you should come back immediately, but I could even send him home uh, without antibiotics. If it was a younger patient with a 72 year old patient, you know, you're not sure what support they have at home and they may have other comorbidities. So, um, and, and, you know, um, it'd be safe to give IV fluids and antibiotics, but this patient could be managed, um, with just, uh, an oral antibiotics and um, and, and, and potentially sent home. Um So uh case 3, uh 65 year old female, it's generalized abdominal tenderness. Uh heart rate is 120 the BP is a bit on the lower side. Excuse me, that's the CT scan there. So, what would be, uh what, what are we thinking here? This is obviously, you know, patients quite unwell. She's in um uh probably in septic shock, uh generalized tenderness and looking at the CT scan, we have this, um, appearances of, uh, you know, variegation. So, stool uh has got, uh, you know, um this uh solid structure, the stool fat and, uh, you know, the bulky fiber. And then there is, uh uh yes. So that's perforated diver diverticulitis. Uh But there is appearance of stool like structure outside the bowel wall as well. So that bit there where the, um, yes, II think, uh that the Hartmann's procedure would probably be uh the best thing. This is a quick hit and run. You know, you don't really want to hang about trying to think of nice is here. Uh There is, uh what looks like stool in the peritoneal cavity outside the bowel. Um So we just, um, you know, get this patient prepared, take to theater and bring the stone out. Um Absolutely, absolutely. So unwell patients, you know, um, just always, you know, the safest, quickest operation would be the right answer. Uh And this is probably the last case. Um, again, you know, as a 48 year old male, he's had some previous episodes of diverticulitis which were treated uh with antibiotics. Now, he's come in with lower abdominal pain and constipation, um, absolute constipation. Um That's the CT scan there. It is, um, uh, you know, sort of frontal view, um which shows that uh the descending colon is coming down on the left side, just the lateral, most part of his left side of his abdomen. And then there is this um thickening there and, and then the bowel wall is not as uh distended that it was up there. Um, for this kind of patient, you know, he's a 48 year old man. He's got some lower abdominal pain. He's I II should have given maybe more details. But um uh he's, well, you know, his observations are fine, his tummy is distended and re but soft. Um So looking at that CT scan, uh what are we uh thinking in terms of uh what could be the diagnosis? No, I suppose, you know, um he's had a few episodes of previous uh diverticulitis. Um and with all that chronic uh type of inflammation or recurrent inflammation going on, he could have developed a scarring there, there is a bit of thickening and, you know, you can't absolutely rule out a cancer causing that blockage, but there is a scarring there and probably a stricture, of course, uh related to the diverticular disease and, um, you know, what would we do with this? Yeah. Yeah, the small bowel is not uh very dilated, there is some dilatation of small bowel here. Um, so I would say that, um, you know, while it is not massively dilated, it is probably sort of weaning back into the small bowel as well. Um So in a, in a stricture type of situation, you know, ideally what we want to do is to resuscitate the patient, um, get them. Uh well, and then, uh you know, with the incompetent dial valve, um we could, um basically, you know, this is a stricture, it's not going to fix itself and we can't rule out the cancer. Uh We could do a flexible sigmoidoscopy distally because the bowel will be empty and look at that stricture and take biopsies and have done that in the past. Um mm And we could put a temporary stent in. We had the, if you had that facility and it was technically feasible to put that stent in. Um And uh then uh in a few days time, once the bowels have moved and we can able to prepare the bowel, we can take them for a resection or uh if we had the facility, then we would uh just uh take them uh to theater and uh do an one to watch and do a primary and anastomosis. And in this case, I would favor a resection. Uh an ontological resection like you do for a um a sigmoid tumor, uh a high anterior resection with primary anastomosis and uh because he's young and otherwise fit, I probably not uh um defunction him, you know, with an sy. So that's good. That's good. That's good. Yes. Yes. I think, I think the heart uh resection, primary resection anastomosis will be the best thing here. Um And so that's, I think us, if there are any more questions um or anything, I've, I've tried to catch up with the questions as we went along. But if there are anything more lovely. Well, then, thank you very much. Uh Thanks ever. I really appreciate your comments. Uh But thank you everyone. Uh hopefully, uh we'll catch up again later in some, another uh another session and thank you Ria for helping me today.