Diverticular disease

Question 1

Define diverticulosis

Answer 1

Presence of diverticulae outpoutchings of the colonic mucosa & submucosa through the muscular wall of the large bowel

Question 2

Define diverticular disease

Answer 2

Diverticulosis associated w/ COMPLICATIONS (e.g. haemorrhage, infection, fistulae)

Question 3

Define diverticulitis

Answer 3

Acute inflammation & infection of colonic diverticulae

Question 4

Classification of acute diverticulitis

4/5

Answer 4

Hinchley classification of acute diverticulitis
Ia - phlegmon
Ib & II - localised abscesses
III - perforation & purulent peritonitis
IV - faecal peritonitis

Question 5

Aetiology of diverticular disease

3

Answer 5

Low fibre diet leads to loss of stool bulk
Leads to high colonic intraluminal pressure to propel stool out
This leads to herniation of mucosa & submucosa through muscularis

Question 6

Pathogenesis of diverticular disease

4

Answer 6

Most common in sigmoid & descending colon (but can be right sided)
NOT found in rectum
Found particularly at sites of nutrient artery penetration
Diverticular obstruction by thickened faeces can lead to bacterial overgrowth, toxin production & mucosal injury —> diverticulitis, perforation, pericolic phlegm, abscess, ulceration & fistula or stricture formation

Question 7

Epidemiology of diverticular disease

prevalence, industrialised, age, right sided

Answer 7

Diverticular disease is VERY COMMON
60% people living in industrialised cities will develop colonic diverticulae
Rare <40 yrs
Right sided diverticulae more common in Asia

Question 8

Presenting symptoms of diverticular disease

general + 3

Answer 8

Often ASYMPTOMATIC (80-90%)

Complications can lead to:
PR bleeding
Diverticulitis (LIF & lower abdo pain, fever)
Diverticular fistulation (pneumaturia, faecaluria, recurrent UTI)

Question 9

Signs of diverticulitis on physical examination

Answer 9

Tender abdomen & signs of local/generalised peritonitis if a diverticulum has perforated

Question 10

Investigations for diverticular disease

4

Answer 10

Bloods
Barium enema
Flexible sigmoidoscopy & colonoscopy
Acute

Question 11

Investigations for diverticular disease - bloods

2

Answer 11

FBC - increased WCC & CRP

Check clotting & cross match if bleeding

Question 12

Investigations for diverticular disease - barium enema

3

Answer 12

Shows presence of diverticulae - saw-tooth appearance of lumen
Reflects pseudo hypertrophy of circular muscle
Should NOT be performed in acute setting due to high risk of perforation

Question 13

Investigations for diverticular disease - flexible sigmoidoscopy & colonoscopy

Answer 13

Diverticulae can be visualised & other pathology excluded (e.g. polyps & tumours)

Question 14

Investigations for diverticular disease - in acute setting

Answer 14

CT scan for evidence of diverticular disease & complications may be performed

Question 15

Management of diverticular disease

4

Answer 15

Asymptomatic
GI bleed
Diverticulitis
Surgery

Question 16

Management of diverticular disease - asymptomatic

2

Answer 16

Soluble high fibre diet (20-30 g/day)

Some drugs are under investigation for their use in preventing recurrent flares

Question 17

Management of diverticular disease - GI bleed

2

Answer 17

PR bleeding usually managed conservatively w/ IV rehydration, antibiotics & blood transfusion if necessary
Angiography & embolisation or surgery if severe

Question 18

Management of diverticular disease - diverticulitis

4

Answer 18

IV antibiotics
IV fluid rehydration
Bowel rest
Abscesses may be drained by radiologically sited drains

Question 19

Management of diverticular disease - surgery

3/4

Answer 19

May be necessary in patients w/ recurrent attacks or complications (e.g. perforation or peritonitis)
Open surgery:
- Hartmann’s procedure (proctosigmoidectomy leaving stoma)
- One-stage resection & anastomosis (risk of leak) w/without defunctioning stoma
Laprascopic drainage, peritoneal lavage & drain placement can be effective

Question 20

Complications of diverticular disease

7

Answer 20

Diverticulitis
Pericolic abscess
Perforation
Faecal peritonitis
Colonic obstruction
Fistula formation (bladder, small intestine, vagina)
Haemorrhage

Question 21

Prognosis of diverticular disease

Answer 21

10-25% have 1+ episodes of diverticulitis