Acute diverticulitis Flashcards
What is diverticular disease?
- diverticula are acquired outpouchings of the colonic mucosa and overlying connective tissue through the colonic wall
- tends to occur along the lines where the penetrating colonic arteries transverse the colonic wall between the taenia coli
What is the common age of presentation for diverticular disease?
50-70y/o
- becoming more common at progressively younger ages
What are the potential complications of diverticular disease?
- Pericolic or paracolic mass/abscess
- Peritonitis
- Diverticular fistula
- Stricture formation
- Haemorrhage
How does a pericolic or parabolic mass/abscess arise in diverticular disease?
- Acute diverticulitis may progress to persistent pericolic infection with thickening of surrounding tissues and the formation of a mass
- if this suppurates, a pericolic abscess forms
- enlargement and extension of this into the paracolic area leads to a paracolic abscess
How does a peritonitis arise in diverticular disease?
- perforation of a pericolic/paracolic abscess usually leads to purulent peritonitis
- direct perforation of the acute diverticular segment leads to faeculent peritonitis
- features are the same as acute diverticulitis, with also severe abdo pain, and generalised guarding + rigidity
What is a fistula?
An abnormal connection/ communication between two epithelial line surfaces
How do fistula arise in diverticular disease?
- acute infection with paracolic sepsis may drain by perforation into adjacent structures
- this is typically the posterior vaginal vault in women or the bladder in either sex
- colovesical fistula leads to recurrent UTI
- colovaginal fistula leads to faeculent per vagina discharge
How does stricture formation arise in diverticular disease?
- chronic or repetitive inflammatory episodes may lead to fibrosis and narrowing of the colon
- a history of recurrent diverticulitis with recurrent colicky pain, distension, bloating suggests stricture formation
What is the common presentation of patient with acute diverticulitis?
- swinging fever
- fluctuating tachycardia
- tenderness across abdomen which is maximal in the LIF
What might the blood results of a patient with acute diverticulitis show?
- Low haemoglobin
- Raised WCC
- Low platelets
- Low K+
- Raised creatinine
- Raised bilirubin
- Low ALP
- Raised CRP
What are the differential diagnoses for diverticulitis?
- IBS
- Appendicitis
- Crohns
- Colorectal cancer
- Ruptured ovarian cyst
- Ectopic pregnancy
- PID
How is diverticular disease diagnosed?
- Elective diagnosis usually by double contrast barium enema - can be used to assess possible stricture formation
- Hb, WCC, CRP during an acute episode of inflammation
- CT = test of choice when identifying complications
What is the medical treatment for acute diverticulitis?
- High fibre diet, high fluid intake, stool softeners to reduce intracolonic pressure
- IV abx (amoxicillin 500mg TDS, metronidazole 500mg TDS, gentamicin OD) during acute infective exacerbations
- recurrent infective episodes may be prevented by a 6-week Cours of oral abx (ciprofloxacin 500mg)
- Significant paracolic abscess may be drained by radiological guidance
What is the surgical management for acute diverticulitis?
- Procedure of choice = resection
- resection is indicated for:
(a) acute inflammation failing to respond to medical management
(b) undrainable paracolic sepsis
(c) free perforation - Affected region should be resected (segmental colectomy)
- ends may be reanastomosed if they are healthy and the patient’s general condition is suitable - Hartmann’s type resection
- Stricture may be treated by elective resection or balloon dilatation
- Diverticular fistula may be treated by elective resection to prevent recurrent infection
