Diverticular disease Flashcards
Meckel’s Diverticulum
Ileal remnant of vitellointestinal duct - joins yoke sac to midgut lumen
Rule of 2s Meckel’s diverticulum
- 2 inches long
- 2 ft from ileocaecal valve
- 2% of population
- 2% symptomatic
- Contain ectopic gastric or pancreatic tissue
Presentation of symptomatic Meckel’s
- Rectal bleeding: from gastric mucosa
- Diverticulitis mimicking appendicitis
- Intussusception
- Volvulus
- Malignant change: adenocarcinoma
- Raspberry tumour: mucosa protruding at umbilicus
- Littre’s Hernia: herniation of Meckel’s
Diagnosis and tx of Meckel’s
Diagnosis: Tc pertechnecate scan ( +ve in 70%)
Tx
• Surgical resection
Intussusception
Portion of intestine invaginates into own lumen
Mesenteric Adenitis
• Viral infection / URTI → enlargement of mesenteric
lymph nodes
• pain, tenderness and fever
- Post URTI
- Headache + photophobia
- Higher temperature
- Tenderness is more generalised
- Lymphocytosis
Diverticulum
Out-pouching of tubular structure
True = composed of complete wall (e.g. Meckel’s)
False = composed of mucosa only (pharyngeal,
colonic)
Diverticular disease
Symptomatic diverticulosis
Diverticulitis
Inflammation of diverticula
Pathophysiology of diverticular disease
Associated with:
- ↑ intraluminal pressure
- Low fibre diet: no osmotic effect to keep stool wet
• Mucosa herniates through muscularis propria at points
of weakness where perforating arteries enter.
• Most commonly located in sigmoid colon
Symptoms of diverticular disease
- Altered bowel habit
- Nausea
- Flatulence
- intermittent lower abdominal pain, typically colicky - Relieved by defecation
Treatment of uncomplicated diverticular disease
- High fibre diet
- simple analgesia
- oral fluid intake
- mebeverine (anti-spasmodic) may help
- Elective resection for chronic pain
Failure to respond:
- embolisation or surgical resection
Presentation of
acute diverticulitis
Abdominal pain and tenderness - Typically LIF - Localised peritonitis - Sharp - Worse with movement • Pyrexia
Investigations for diverticulitis
• Bloods
- FBC: ↑WCC
- ↑CRP/ESR
- Amylase
- G+S
• VBG - lactate
• Imaging
- Erect CXR: look for perforation
- AXR: fluid level / air in bowel wall
- First line - Contrast CT Abdo pelvis
• Endoscopy
- Flexi Sig - uncomplicated diverticular disease
- Colonoscopy: not in acute attack
Mx of mild attacks of acute diverticulitis
At home with bowel res - fluids only
Co-amoxiclav and metronidazole
When to admit diverticulitis
- Unwell
- Fluids can’t be tolerated
- Pain can’t be controlled
Mx of moderate to severe diverticulitis
• Medical
- NBM
- IV fluids
- Analgesia
- Antibiotics: cefuroxime + metronidazole
• Surgical:
- Hartmann’s to resect diseased bowel
- May consider lap washout for Hinchey 3
Indications for surgery
- Perforation
- Large haemorrhage
- Stricture → obstruction
Complications of diverticulitis
- Perforation
- Haemorrhage
- Abscess
- Fistulae - UTIs
- Strictures
Perforation presentation and management
- Sudden onset pain (± preceding diverticulitis)
- Generalised peritonitis and shock
- CXR: free air under diaphragm
Tx: Hartmann’s
Presentation, investigations and Tx of haemorrhage
Presentation:
- Sudden, painless bright red PR bleed
Ix:
Mesenteric angiography or colonoscopy
Tx
- Usually stops spontaneously
- May need transfusion
- Colonoscopy ± diathermy / adrenaline
- Embolisation
- Resection
Presentation and management of abscess
Walled-off perforation
Presentation:
• Swinging fever
• Localising signs: e.g. boggy rectal mass
• Leukocytosis
Tx:
<5cm - Abx
> 5cm - Abx+ CT/US-guided drainage
Tx of stricture
Resection
Stenting
Risk factors
Age Low dietary fibre intake Obesity Smoking FHx NSAIDs Ehlos Danlos
