[17] Diverticular Disease Flashcards
What is a diverticulum?
An outpouching of the bowel wall that is composed of mucosa
Where are diverticulum found?
Most commonly found in the sigmoid colon, yet can be present throughout the large bowel and less commonly in the small bowel
What are the three manifestations of diverticulum?
- Diverticulosis
- Diverticular disease
- Diverticulitis
What is diverticulosis?
The presence of diverticulum
What is diverticular disease?
Symptomatic diverticulum
What is diverticulitis?
Inflammation of the diverticulum
What % of people over 50 years is diverticulosis present in?
50%
What % of people over the age of 80 years is diverticulosis present in?
70%
What % of cases of diverticulosis become symptomatic?
25%
Which gender is more commonly affected by diverticulosis?
Men (1.6 : 1)
Where is diverticulosis most prevalent?
Developed countries
What happens in an aging bowel?
It becomes naturally weakened in certain areas over time
How does the natural weakening of an aging bowel lead to diverticulosis?
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
What can accumulate in the pockets made in diverticulosis?
Bowel contents, including bacteria
What can happen when diverticulum get inflamed?
They can perforrate and result in peritonitis
What are the risk factors for the formation of diverticulum?
- Low dietary fibre intake
- Obesity (in younger patients)
- Smoking
- Family history
- NSAID use
How is diverticulosis discovered in a large proportion of individuals?
Found incidentally, such as during routine colonoscopy or CT imaging, as they are asymptomatic
How might a patient with simple diverticular disease present?
With left lower abdominal pain, altered bowel habit, nausea, or flatulence
Describe the pain in simple diverticular disease?
Typically a coliky pain, relieved by defecation
What is the presentation of diverticulitis dependant on?
The specific complication of the diverticulum
What are the potential presentations of diverticulitis?
- Abdominal pain and localised tenderness
- PR bleeding
- Anorexia, nausea, or vomiting
Where is the abdominal pain and localised tenderness classically felt in diverticular disease?
In the left iliac fossa
How can a perforated diverticulum present?
With signs of localised or generalised peritonitis
What may mask the symptoms of diverticulitis, even if perforated?
If the patient is taking corticosteroids or immunosuppressants
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
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
What causes the mass on PR examination in severe diverticulitis?
It is secondary to asbcess formation
What can happen in severe or chronic cases of diverticulitis?
Fistuale can form
What are the most common types of fistulas formed in severe or chronic diverticulitis?
Colovesical or colovaginal
How can colovesical fistulas present?
- Pneumoturia
- Faecaluria
- Recurrent UTIs
How can colovaginal fistulas present?
- Copious vaginal discharge
- Recurrent vaginal infections
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
What complications can recurrent or chronic diverticular disease result in?
- Bowel obstruction
- Pericolic abscesses
- Fistula formation
How does diverticular disease lead to bowel obstruction?
It occurs secondary to stricture formation
How can bowel obstruction caused by diverticular disease be managed?
Either via stenting or bowel resection
How can pericolic abscesses caused by diverticular disease be managed initially?
Antibiotics and bowel rest
What further management can be trialled in pericolic abscess?
CT guided drainage or a laparoscopic washout
What does fistula formation caused by diverticular disease often require as management?
Surgical resection and repair
What are the most important differential diagnoses for diverticular disease?
- Inflammatory bowel disease
- Bowel cancer
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
What are the other causes of abdominal pain that should be considered in suspected diverticulitis?
- Appendicitis
- Mesenteric ischaemia
- Gynaecological causes
- Renal stones
What investigations may be done in suspected diverticular disease?
- Routine blood tests
- Blood gas (either ABG or VBG)
- Urine dipstick
- Imaging
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
When will a blood gas be required in diverticulitis?
In severe cases
Why may a blood gas be useful in severe diverticulitis?
To check lactate level, assessing for any sepsis or bowel ischaemia
Why may a urine dipstick be helpful in suspected diverticulitis?
May help exclude any urological causes, e.g. left renal colic or pyelonephritis
What imaging is a good initial approach in a patient with suspected diverticular disease?
A flexible sigmoidoscopy
Why is a flexible sigmoidoscopy a good initial approach in a patient with suspected diverticular disease?
Because it will identify any obvious rectosigmoid lesion
Why should a sigmoidoscopy or colonoscopy never be performed in any presenting cases of suspected diverticulitis?
Due to the increased risk of perforation
What further imaging may be required dependant on clinical findings in diverticular disease?
- Abdominal x-ray
- Erect chest x-ray
- CT abdo-pelvis scan
Why may an abdominal x-ray be required in suspected diverticular disease?
To exclude obstruction
Why may an erect CXR be required in suspected diverticular disease?
If perforation is suspected
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
What is the use of contrast studies in diverticular disease?
Investigate any fistula that have developed
How can patients with mild, uncomplicated diverticulitis be managed?
Often can be managed at home with antibiotics, analgesia, and encouraging intake of clear fluids
What is recommended as first line analgesia in mild uncomplicated diverticulitis?
Paracetamol
Why is opiod-based analgesia avoided in diverticulitis?
As it can cause constipation, and worsen the clinical course of the diverticular disease
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
What is required with any significant PR haemorrhage?
Resuscitation with IV fluids and blood products
What is true of a diverticular bleed in most patients?
It is self limiting
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
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%)
What % of patients with diverticular disease will eventually require surgery?
15-30%
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
What is the mortality rate of perforation in diverticular disease?
Up to 50%
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
When is laparoscopic peritoneal lavage often used?
- Younger patients
- Those with higher BMIs
- Low ASA grades
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
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
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
What may be possible with a Hartmann’s procedure at a later date?
Anastomosis with reversal of the colostomy
