Diverticular Disease, El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
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.

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.

 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 seeing the video clips in full
 screen mode.

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.

Video Endoscopic Sequence 2 of 7.

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.

                                         Pubmed   

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.

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 .

 

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.

Video Endoscopic Sequence 4 of 7.

 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.

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.

Video Endoscopic Sequence 5 of 7.

 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.

 

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.

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.

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.

Video Endoscopic Sequence 7 of 7.

 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.

 

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

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. 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.

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. 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.

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.  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.

 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.

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.

Video Endoscopic Sequence 1 of 3.

 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
.

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.

Video Endoscopic Sequence 2 of 3.

 Endoscopic Image of Colon Diverticula

 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. 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.

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. 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 a mucopurulent exudate and edema.

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 a
 mucopurulent exudate and edema.

 
 In some rural areas of the world, particularly in Africa,
 diverticula are rarely seen.

Diverticular Disease of the Sigmoid Colon . The image and the video clip display a diverticulitis of the sigmoid, there are  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.

            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. 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 are pseudo tumor appearance The cat scan displayed thickened colonic walls 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.                                                                                     Medline.
 

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.

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.

 

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.

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.

                                           Medline

More inespecific ulcerated lesions.

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. 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.

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.

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

Video Endoscopic Sequence 2 of 5.

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

 

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

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.

 

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

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.

 

Final status of closing the micro perforation.  The patient was managed as an ambulatory basis with wide spectrum antibiotics, improving the clinical course.

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.
 

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

Video Endoscopic Sequence 1 of 4.

Diverticulitis.

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

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.

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

Video Endoscopic Sequence 3 of 4.

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

More foci of diverticulitis.

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.

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

“ Foot Steps Impression”

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

 

 

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

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.

 

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.

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. 

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. These complications always require treatment to prevent them from progressing and causing serious illness.

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. These
    complications always require treatment to prevent them from
    progressing and causing serious illness.

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

 Abscess, Perforation and Peritonitis The infection causing
 diverticulitis often clears up after a few days of treatment with
 antibiotics. If the condition gets worse, an abscess may form in
 the colon. An abscess is an infected area with pus that may cause
 swelling and destroy tissue. Sometimes, the infected diverticula
 may develop small holes, called perforations. These perforations
 allow pus to leak out of the colon into the abdominal area. If the
 abscess is small and remains in the colon, it may clear up after
 treatment with antibiotics. If the abscess does not clear up with
 antibiotics, the doctor may need to drain it. To drain the abscess,
 the doctor uses a needle and a small tube called a catheter. The
 doctor inserts the needle through the skin and drains the fluid
 through the catheter. This procedure is called "percutaneous
 catheter drainage" Sometimes surgery is needed to clean the
 abscess and, if necessary, remove part of the colon. A large
 abscess can become a serious problem if the infection leaks out
 and contaminates areas outside the colon. Infection that spreads
 into the abdominal cavity is called peritonitis. Peritonitis requires
 immediate surgery to clean the abdominal cavity and remove the
 damaged part of the colon. Without surgery, peritonitis can be
 fatal.

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

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

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.

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.

CA 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.

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.  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. 

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.
 
  
 

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.

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.

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

Video Endoscopic Sequence 3 of 4.

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

 A fecalith is seen at the sigmoid.

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 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.

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.

                                          
Medline.

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

Video Endoscopic Sequence 2 of 5.

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





                                          Medline.                                                     

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.

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

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
.

Cystography.  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.

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
.

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.

Video Endoscopic Sequence 3 of 8.

 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.

 

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

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, like BE, 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.

Video Endoscopic Sequence 5 of 8.

 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.

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.

Video Endoscopic Sequence 6 of 8.

 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 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.

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.

 

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.

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

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 hospitalized, and
 no hemodynamics changes were observed.
 His hemoglobin was 9.0 mg/dl.
   

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.

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
.

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

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 related
 to complications of diverticulosis, which are mainly
 diverticulitis and lower GI bleeding. These occur in 10-20%
 of patients with diverticulosis during their lifetime.

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.

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.

Donut shape blood clot around a diverticula  is observed.

Video Endoscopic Sequence 5 of 15.

 
 
Donut shape blood clot around a diverticula is observed.  

Big diverticula with clot blood remains.

Video Endoscopic Sequence 6 of 15.

 Big diverticula with clot blood remains.

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

Video Endoscopic Sequence 7 of 15.

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

Same case as the 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.

Video Endoscopic Sequence 8 of 15.

 Same case as the 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.
 
 

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

Video Endoscopic Sequence 9 of 15.

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

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

Video Endoscopic Sequence 10 of 15.

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

         Several diverticulae are observed.

Rest of  of blood clot at one diverticulum.

Video Endoscopic Sequence 11 of 15.

 Rest of of blood clot at one diverticulum.

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

Video Endoscopic Sequence 12 of 15.

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

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

Video Endoscopic Sequence 13 of 15.

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

Several diverticulae are observed with blood remains.

Video Endoscopic Sequence 14 of 15.


 Several diverticulae are observed with blood remains.

 

Endoscope view of the colon affected by diverticular disease. Many diverticula are seen in the sigmoid.

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, due to a actively bleeding colonic diverticula.

Surgical Resection Specimen

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

To enlarge the image click here

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

Diverticulitis.

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

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

Perforating diverticula.

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

 

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.

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.

Diverticulae with Fecalith. 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.

Video Endoscopic Sequence 2 of 2.

Diverticulae with Fecaliths.

 

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

 

Video Endoscopic Sequence 2 of 4.

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

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.

Video Endoscopic Sequence 3 of 4.

 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.

 

Methylene blue stain.

Video Endoscopic Sequence 4 of 4.

Methylene blue stain

DivertPolipzx1

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

 

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

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.

DivertPolipzx4

Video Endoscopic Sequence 4 of 12.

 

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

Video Endoscopic Sequence 5 of 12.

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

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.

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.

With the forceps biopsy, the fibrin layer is removed.

Video Endoscopic Sequence 7 of 12.

With the forceps biopsy, the fibrin layer is removed

 

Video Endoscopic Sequence 8 of 12.

The polyps is removed with polypectomy snare

 

Status post polypectomy there are scanty remnants of the polyp.

Video Endoscopic Sequence 9 of 12.

Status post polypectomy there are scanty remnants of the polyp.

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

Video Endoscopic Sequence 10 of 12.

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

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.

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

The polyp with basket is extracted.                     The polyp with basket retriever is extracted.

Video Endoscopic Sequence 12 of 12.

The polyp with basket retriever is extracted

 

 

Video Endoscopic Sequence 1 of 2.

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

 

Diverticular Disease

Video Endoscopic Sequence 2 of 2.

More view of this case

DivertPuys1

 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, it management
 with antibiotics.