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ANKI GI > [17] Diverticular Disease > Flashcards

[17] Diverticular Disease Flashcards

1
Q

What is a diverticulum?

A

An outpouching of the bowel wall that is composed of mucosa

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2
Q

Where are diverticulum found?

A

Most commonly found in the sigmoid colon, yet can be present throughout the large bowel and less commonly in the small bowel

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3
Q

What are the three manifestations of diverticulum?

A
  • Diverticulosis
  • Diverticular disease
  • Diverticulitis
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4
Q

What is diverticulosis?

A

The presence of diverticulum

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5
Q

What is diverticular disease?

A

Symptomatic diverticulum

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6
Q

What is diverticulitis?

A

Inflammation of the diverticulum

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7
Q

What % of people over 50 years is diverticulosis present in?

A

50%

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8
Q

What % of people over the age of 80 years is diverticulosis present in?

A

70%

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9
Q

What % of cases of diverticulosis become symptomatic?

A

25%

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10
Q

Which gender is more commonly affected by diverticulosis?

A

Men (1.6 : 1)

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11
Q

Where is diverticulosis most prevalent?

A

Developed countries

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12
Q

What happens in an aging bowel?

A

It becomes naturally weakened in certain areas over time

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13
Q

How does the natural weakening of an aging bowel lead to diverticulosis?

A

The movement of stool will cause an increase in luminal pressure, resulting in a protrusion or outpouching of the mucosa through weaker areas of the bowel wall, creating pockets

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14
Q

What can accumulate in the pockets made in diverticulosis?

A

Bowel contents, including bacteria

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15
Q

What can happen when diverticulum get inflamed?

A

They can perforrate and result in peritonitis

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16
Q

What are the risk factors for the formation of diverticulum?

A
  • Low dietary fibre intake
  • Obesity (in younger patients)
  • Smoking
  • Family history
  • NSAID use
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17
Q

How is diverticulosis discovered in a large proportion of individuals?

A

Found incidentally, such as during routine colonoscopy or CT imaging, as they are asymptomatic

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18
Q

How might a patient with simple diverticular disease present?

A

With left lower abdominal pain, altered bowel habit, nausea, or flatulence

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19
Q

Describe the pain in simple diverticular disease?

A

Typically a coliky pain, relieved by defecation

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20
Q

What is the presentation of diverticulitis dependant on?

A

The specific complication of the diverticulum

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21
Q

What are the potential presentations of diverticulitis?

A
  • Abdominal pain and localised tenderness
  • PR bleeding
  • Anorexia, nausea, or vomiting
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22
Q

Where is the abdominal pain and localised tenderness classically felt in diverticular disease?

A

In the left iliac fossa

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23
Q

How can a perforated diverticulum present?

A

With signs of localised or generalised peritonitis

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24
Q

What may mask the symptoms of diverticulitis, even if perforated?

A

If the patient is taking corticosteroids or immunosuppressants

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25
Describe the PR bleeding in diverticular disease?
It is usually sudden, and can sometimes be painless. Large amounts of blood and clots may be passed, even with minimal pain
26
What is found on PR examination in diverticular disease?
PR examination is most commonly unremarkable, yet in severe cases there can be a mass present
27
What causes the mass on PR examination in severe diverticulitis?
It is secondary to asbcess formation
28
What can happen in severe or chronic cases of diverticulitis?
Fistuale can form
29
What are the most common types of fistulas formed in severe or chronic diverticulitis?
Colovesical or colovaginal
30
How can colovesical fistulas present?
* Pneumoturia * Faecaluria * Recurrent UTIs
31
How can colovaginal fistulas present?
* Copious vaginal discharge * Recurrent vaginal infections
32
What has been shown to be true in younger patients with diverticular disease?
They have more active disease, with high re-occurence and complication rates
33
What complications can recurrent or chronic diverticular disease result in?
* Bowel obstruction * Pericolic abscesses * Fistula formation
34
How does diverticular disease lead to bowel obstruction?
It occurs secondary to stricture formation
35
How can bowel obstruction caused by diverticular disease be managed?
Either via stenting or bowel resection
36
How can pericolic abscesses caused by diverticular disease be managed initially?
Antibiotics and bowel rest
37
What further management can be trialled in pericolic abscess?
CT guided drainage or a laparoscopic washout
38
What does fistula formation caused by diverticular disease often require as management?
Surgical resection and repair
39
What are the most important differential diagnoses for diverticular disease?
* Inflammatory bowel disease * Bowel cancer
40
How is inflammatory bowel disease or bowel cancer ruled out as a differential for diverticular disease?
Investigate any patient with suspected diverticular disease with an appropriate imaging study, such as flexible sigmoidoscopy
41
What are the other causes of abdominal pain that should be considered in suspected diverticulitis?
* Appendicitis * Mesenteric ischaemia * Gynaecological causes * Renal stones
42
What investigations may be done in suspected diverticular disease?
* Routine blood tests * Blood gas (either ABG or VBG) * Urine dipstick * Imaging
43
What routine blood tests should be done in any patient with suspected diverticulitis?
* FBC * U&Es * Clotting * LFTs * Group & save, or crossmatch depending on the degree of blood loss
44
When will a blood gas be required in diverticulitis?
In severe cases
45
Why may a blood gas be useful in severe diverticulitis?
To check lactate level, assessing for any sepsis or bowel ischaemia
46
Why may a urine dipstick be helpful in suspected diverticulitis?
May help exclude any urological causes, e.g. left renal colic or pyelonephritis
47
What imaging is a good initial approach in a patient with suspected diverticular disease?
A flexible sigmoidoscopy
48
Why is a flexible sigmoidoscopy a good initial approach in a patient with suspected diverticular disease?
Because it will identify any obvious rectosigmoid lesion
49
Why should a sigmoidoscopy or colonoscopy **never** be performed in any presenting cases of suspected diverticulitis?
Due to the increased risk of perforation
50
What further imaging may be required dependant on clinical findings in diverticular disease?
* Abdominal x-ray * Erect chest x-ray * CT abdo-pelvis scan
51
Why may an abdominal x-ray be required in suspected diverticular disease?
To exclude obstruction
52
Why may an erect CXR be required in suspected diverticular disease?
If perforation is suspected
53
What is the use of CT scanning in suspected diverticular disease?
It can provide a high level of accuracy in diagnosing symptomatic diverticular disease Useful in patients where perforation or an alternative diagnosis are suspected
54
What is the use of contrast studies in diverticular disease?
Investigate any fistula that have developed
55
How can patients with mild, uncomplicated diverticulitis be managed?
Often can be managed at home with antibiotics, analgesia, and encouraging intake of clear fluids
56
What is recommended as first line analgesia in mild uncomplicated diverticulitis?
Paracetamol
57
Why is opiod-based analgesia avoided in diverticulitis?
As it can cause constipation, and worsen the clinical course of the diverticular disease
58
What features suggest the need for hospitalisation with diverticular disease?
* Pain is not controlled with simple analgesia, or concerns of dehydration * The patient has significant co-morbidities, or is immunocompromised * Significant PR bleeding * Suspicion of peritonitis, warranting imaging and active observation * Symptoms persisting for longer than 48 hours at home with conservative management
59
What is required with any significant PR haemorrhage?
Resuscitation with IV fluids and blood products
60
What is true of a diverticular bleed in most patients?
It is self limiting
61
What are the options for management of a diverticular bleed in cases that do not settle with conservative approaches?
* Embolisation * Intra-arterial vasopressing * Surgical resection
62
Why is it best to discuss early with interventional radiologists for planning further management options?
Because if a second bleeding episode occurs, there is a significant chance of further episodes (up to 50%)
63
What % of patients with diverticular disease will eventually require surgery?
15-30%
64
What are the indications for emergency surgery in diverticular disease?
* Perforation with faecal peritonitis * Sepsis, not responding to antibiotic therapy * Failure to improve with conservative management
65
What is the mortality rate of perforation in diverticular disease?
Up to 50%
66
What are the options for emergency intervention in diverticular disease?
* Bowel resection, either with primary anatomosis or as a Hartmann's procedure * Laparoscopic peritoneal lavage
67
When is laparoscopic peritoneal lavage often used?
* Younger patients * Those with higher BMIs * Low ASA grades
68
How do resection and lavage compare for acute perforated diverticulitis?
There is no difference in mortality, 30-day reoperations, and unplanned readmissions Lavage was associated with higher rates of intra-abdominal abscesses, peritonitis, and increased long-term emergency re-operations
69
When might elective surgical intervention be indicated in diverticular disease?
In patients with chronic symptoms, significant co-morbidities, immunosuppression, or recurrent disease May also be used in cases where diverticulitis was initially treated by percutaneous drainage
70
What is a Hartmann's procedure?
An emergency surgical procedure whereby the affected area of the colon (sigmoid colon) is resected, with the formation of an end colostomy and the closure of the rectal stump
71
What may be possible with a Hartmann's procedure at a later date?
Anastomosis with reversal of the colostomy

ANKI GI (43 decks)

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