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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
Q

Describe the PR bleeding in diverticular disease?

A

It is usually sudden, and can sometimes be painless. Large amounts of blood and clots may be passed, even with minimal pain

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26
Q

What is found on PR examination in diverticular disease?

A

PR examination is most commonly unremarkable, yet in severe cases there can be a mass present

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27
Q

What causes the mass on PR examination in severe diverticulitis?

A

It is secondary to asbcess formation

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28
Q

What can happen in severe or chronic cases of diverticulitis?

A

Fistuale can form

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29
Q

What are the most common types of fistulas formed in severe or chronic diverticulitis?

A

Colovesical or colovaginal

30
Q

How can colovesical fistulas present?

A
  • Pneumoturia
  • Faecaluria
  • Recurrent UTIs
31
Q

How can colovaginal fistulas present?

A
  • Copious vaginal discharge
  • Recurrent vaginal infections
32
Q

What has been shown to be true in younger patients with diverticular disease?

A

They have more active disease, with high re-occurence and complication rates

33
Q

What complications can recurrent or chronic diverticular disease result in?

A
  • Bowel obstruction
  • Pericolic abscesses
  • Fistula formation
34
Q

How does diverticular disease lead to bowel obstruction?

A

It occurs secondary to stricture formation

35
Q

How can bowel obstruction caused by diverticular disease be managed?

A

Either via stenting or bowel resection

36
Q

How can pericolic abscesses caused by diverticular disease be managed initially?

A

Antibiotics and bowel rest

37
Q

What further management can be trialled in pericolic abscess?

A

CT guided drainage or a laparoscopic washout

38
Q

What does fistula formation caused by diverticular disease often require as management?

A

Surgical resection and repair

39
Q

What are the most important differential diagnoses for diverticular disease?

A
  • Inflammatory bowel disease
  • Bowel cancer
40
Q

How is inflammatory bowel disease or bowel cancer ruled out as a differential for diverticular disease?

A

Investigate any patient with suspected diverticular disease with an appropriate imaging study, such as flexible sigmoidoscopy

41
Q

What are the other causes of abdominal pain that should be considered in suspected diverticulitis?

A
  • Appendicitis
  • Mesenteric ischaemia
  • Gynaecological causes
  • Renal stones
42
Q

What investigations may be done in suspected diverticular disease?

A
  • Routine blood tests
  • Blood gas (either ABG or VBG)
  • Urine dipstick
  • Imaging
43
Q

What routine blood tests should be done in any patient with suspected diverticulitis?

A
  • FBC
  • U&Es
  • Clotting
  • LFTs
  • Group & save, or crossmatch depending on the degree of blood loss
44
Q

When will a blood gas be required in diverticulitis?

A

In severe cases

45
Q

Why may a blood gas be useful in severe diverticulitis?

A

To check lactate level, assessing for any sepsis or bowel ischaemia

46
Q

Why may a urine dipstick be helpful in suspected diverticulitis?

A

May help exclude any urological causes, e.g. left renal colic or pyelonephritis

47
Q

What imaging is a good initial approach in a patient with suspected diverticular disease?

A

A flexible sigmoidoscopy

48
Q

Why is a flexible sigmoidoscopy a good initial approach in a patient with suspected diverticular disease?

A

Because it will identify any obvious rectosigmoid lesion

49
Q

Why should a sigmoidoscopy or colonoscopy never be performed in any presenting cases of suspected diverticulitis?

A

Due to the increased risk of perforation

50
Q

What further imaging may be required dependant on clinical findings in diverticular disease?

A
  • Abdominal x-ray
  • Erect chest x-ray
  • CT abdo-pelvis scan
51
Q

Why may an abdominal x-ray be required in suspected diverticular disease?

A

To exclude obstruction

52
Q

Why may an erect CXR be required in suspected diverticular disease?

A

If perforation is suspected

53
Q

What is the use of CT scanning in suspected diverticular disease?

A

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
Q

What is the use of contrast studies in diverticular disease?

A

Investigate any fistula that have developed

55
Q

How can patients with mild, uncomplicated diverticulitis be managed?

A

Often can be managed at home with antibiotics, analgesia, and encouraging intake of clear fluids

56
Q

What is recommended as first line analgesia in mild uncomplicated diverticulitis?

A

Paracetamol

57
Q

Why is opiod-based analgesia avoided in diverticulitis?

A

As it can cause constipation, and worsen the clinical course of the diverticular disease

58
Q

What features suggest the need for hospitalisation with diverticular disease?

A
  • 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
Q

What is required with any significant PR haemorrhage?

A

Resuscitation with IV fluids and blood products

60
Q

What is true of a diverticular bleed in most patients?

A

It is self limiting

61
Q

What are the options for management of a diverticular bleed in cases that do not settle with conservative approaches?

A
  • Embolisation
  • Intra-arterial vasopressing
  • Surgical resection
62
Q

Why is it best to discuss early with interventional radiologists for planning further management options?

A

Because if a second bleeding episode occurs, there is a significant chance of further episodes (up to 50%)

63
Q

What % of patients with diverticular disease will eventually require surgery?

A

15-30%

64
Q

What are the indications for emergency surgery in diverticular disease?

A
  • Perforation with faecal peritonitis
  • Sepsis, not responding to antibiotic therapy
  • Failure to improve with conservative management
65
Q

What is the mortality rate of perforation in diverticular disease?

A

Up to 50%

66
Q

What are the options for emergency intervention in diverticular disease?

A
  • Bowel resection, either with primary anatomosis or as a Hartmann’s procedure
  • Laparoscopic peritoneal lavage
67
Q

When is laparoscopic peritoneal lavage often used?

A
  • Younger patients
  • Those with higher BMIs
  • Low ASA grades
68
Q

How do resection and lavage compare for acute perforated diverticulitis?

A

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
Q

When might elective surgical intervention be indicated in diverticular disease?

A

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
Q

What is a Hartmann’s procedure?

A

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
Q

What may be possible with a Hartmann’s procedure at a later date?

A

Anastomosis with reversal of the colostomy

ANKI GI (43 decks)

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