Colorectal - Diverticular Disease

Question 1

What is diverticular disease?

Answer 1

Acquired pseudo-diverticular outpouching of colonic mucosa and submucosal at the antimesenteric side

Question 1

What is the progression of the disease?

Answer 1

Asymptomatic diverticular disease –> Complicated diverticular disease (abscess, fistula, obstruction, peritonitis, sepsis) –> diverticulitis

Question 2

What are the risk factors for diverticular disease?

Answer 2

▪ Diet = lack of dietary fibre or high in red meat / fat
▪ Obesity / lack of physical activity
▪ Genetics = in Caucasian almost always LDD, in Asians / Africans predominant RDD
▪ Others = ADPKD patients on dialysis

Question 3

What is the pathophysiology behind diverticular disease?

Answer 3

1. Increased intraluminal pressure
   ▪ Forces mucosa and submucosal through areas of weakness in gut wall – occurs in the colon as the muscularis propria layer is aggregated into 3 bands (taeniae coli)
   ▪ Associated with lack of dietary fibre
2. Degenerative changes in colonic wall
   ▪ Usually at point of entry of terminal arterial branches where serosa is weakest
   ▪ Associated with weakening of collagen structure with age

Question 4

How does it usually present on history?

Answer 4

Usually presents when there is diverticulitis.

• Abdominal Pain
• Nausea Vomiting
• Constipation/Diarrhea
• Urinary Urgency
• Mucoid PR Bleed (a/w chronic diverticular)

Look out for complications
- LBGIT
- Fistula - Colovesical Fistula common, ask for LUTS
- BO - Pain, Tenderness to Touch, Tinkling Bowel Sounds
- Perforation - LBGIT, Fever, Palpitations, SOB

Question 5

What to look out for one physical examination?

Answer 5

Low-grade fever, Localised LLQ tenderness, ±mass (i.e. abscess / phlegmon)

Question 6

Suspecting diverticular disease, what investigations to order?

Answer 6

Biochemical
1. FBC + CRP/ESR
2. RP
3. PT/PTT - if considering intervention
4. GXM - if considering intervention
5. ABG - if suspecting peritonitis/sepsis
6. Lactate - if suspecting peritonitis/sepsis

Imaging
1. CT AP
▪ Localized bowel wall thickening (>4mm)
▪ Fat stranding: ↑ soft tissue density within pericolonic fat 20 to inflammation
▪ Presence of colonic diverticula
* Complications
- Pericolic Abscess (fluid surrounded by inflammatory changes)
- Fistula (Air within other organs)
- Peritonitis (Free Air)

Question 7

How should you manage uncomplicated diverticular disease?

Answer 7

1. NBM > clear liquid diet > high fibre low residue diet
2. Analgesia
3. IV Abx (Ros/Flagyl) -> Oralise Cipro/Metro (10-14d) (if immunocompetent + clinical judgement)
4. Colonoscopy for patients with high risk features; if at screening age, proceed 4/52 later
5. Prevention Advice
   - Minimise Aspirin/NSAID
   - Weight Loss
   - Smoking cessation

Question 8

For complicated diverticular disease, what classification is used, and how would you manage it?

Answer 8

Hinchey Classification
- Stage 1: Pericolic abscess confined by mesocolon
- Stage 2: Pelvic/Retroperitoneal Abscess
- Stage 3: Purulent Peritonitis
- Stage 4: Fecal Peritonitis

Initial Management is always
1. ABC + NBM + Analgesia + IV Antibiotics + Colonoscopy in 6/52

For Hinchey 1 and 2:
1. IV Abx
2. CT guided percutaneous drainage for larger abscesses (>4cm), if sepsis not resolving with antibiotics
3. Consider elective 1 stage surgery – resection of segmental colectomy with primary anastomosis if unresponsive to 1 and 2

For Hinchey 3 and 4:
1. Emergency Surgery
– Sigmoid resection and primary anastomosis with or without proximal diversion
– Hartmann’s procedure is the preferred option for hemodynamically unstable patients
– In unstable patients – damage control surgery can be considered (i.e. resection & temporary abdominal closure)
– Laparoscopic lavage can be considered in selected patients – lower stoma rates weighed against higher risk of
complications and re-intervention [for Hinchey III]

Question 9

When the patient has diverticular bleed, what is the management?

Answer 9

1. ABC
2. Colonoscopy
3. Angiography/ Embolization
4. Surgical Intervention
   - Consider when pt needed 4 or more PCTs
   - Segmental colectomy (after source of bleeding identified) with restoration of continuity by end-to-end anastomosis (last resort: subtotal colectomy)

Question 10

Let us say the patient has a diverticular bleed proven on CT AP, as well as obstruction 2’ to stricture/abscess formation. What is the issue with the regular management? How would you change your management?

Answer 10

Colonoscopy is contraindicated because of the bowel prep needed.

Emergency surgery will be performed. - segmental colectomy with restoration of continuity by end to end anastomosis.

Question 11

What are the types of fistulas that can form?

Answer 11

1. Colovesical
2. colo-cutaneous
3. colo-uterine
4. colo-enteric
5. colo-vaginal