Diverticular disease

Question 1

What is diverticulosis?

Answer 1

The presence of diverticula outpouchings (diverticulosis concerns MULTIPLE) of the colonic mucosa and submucosa through the muscular wall of the large bowel. They are NOT INFLAMED.

Question 2

What are pseudo- and true diverticula?

Answer 2

True is an outpouching of all three layers of the GI wall; Pseudo is an outpouching through the muscularis.

Question 3

What is diverticular disease?

Answer 3

Diverticulosis associated with complications e.g. haemorrhage, infection, fistulae. This includes diverticulitis i.e. SYMPTOMATIC diverticulosis.

Question 4

What is diverticulitis?

Answer 4

Acute inflammation and infection of colonic diverticulae.

Question 5

What is Hinchey classification of acute diverticulitis? (x4)

Answer 5

Ia: phlegmon (localised, acute inflammation), Ib and II: localised abscesses, III: perforation with purulent peritonitis (purulent refers to containing pus), IV: faecal peritonitis.

Question 6

What are the risk factors of diverticulitis? (x4)

Answer 6

Low fibre diet, obesity, smoking, family history, NSAID use.

Question 7

Why may low fibre diet cause diverticular disease?

Answer 7

Leads to loss of stool bulk, so high colonic intraluminal pressures are needed to propel the stool, leading to herniation of the mucosa and submucosa through the muscularis.

Question 8

What is the location of diverticular disease? (x2 points)

Answer 8

(1) Diverticulae are most common in the sigmoid and descending colon but can be right sided. They are absent from the rectum. (2) Occurs usually at sites of entry of perforating arteries, as these are the weakest areas of colonic wall.

Question 9

What is the epidemiology of diverticular disease: Prevalence? Age? Country?

Answer 9

60% in industrial countries will develop diverticula in the colon. Rare below 40 years old. Right-sided more common in Asia.

Question 10

What are the complications of diverticular disease? (x7)

Answer 10

Diverticulitis, pericolic abscess, perforation, faecal peritonitis, colonic obstruction, fistula formation (bladder, small intestine, vagina), haemorrhage.

Question 11

In diverticular disease abscess: What should you consider if there are no localising signs?

Answer 11

Abscesses tend to have localising signs e.g. pain in one quadrant, boggy rectal mass. If there are no localised signs, remember the saying: PUS SOMEWHERE, PUS NOWHERE = PUS UNDER THE DIAPHRAGM.

Question 12

How is pus under the diaphragm explored?

Answer 12

Aka subphrenic abscess: investigated by USS.

Question 13

How may diverticular disease lead to colonic obstruction? (x2)

Answer 13

Inflammation can lead to narrowing of bowel lumen leading to obstruction, OR a stricture can form from fibrosis arising because of recurrent inflammation.

Question 14

What are the symptoms of diverticular disease? Asymptomatic? (x5, x2, x3)

Answer 14

o 80-90% are asymptomatic. Remember, diverticulosis is defined as ASYMPTOMATIC. Symptoms are associated with complications

o Diverticular disease: altered bowel habit (diarrhoea OR constipation), left iliac fossa or lower abdominal pain, nausea, flatulence, PR bleed.

o Diverticulitis: same features as diverticular disease + fever.

o Diverticular fistulation into bladder: pneumaturia, faecaluria, recurrent UTI.

Question 15

How is pain relieved in diverticular disease?

Answer 15

Defecation.

Question 16

What are the signs of diverticular disease? (x5)

Answer 16

Diverticulitis: tender abdomen, signs of localised/generalised peritonitis if perforation has occurred, pyrexia, tachycardia, decreased bowel sounds.

Question 17

When may you hear increased bowel sounds in diverticular disease?

Answer 17

If diverticulitis leads to obstruction.

Question 18

What are the investigations for diverticular disease? (x4)

Answer 18

o BLOODS: Diverticulitis: increased WCC, increased CRP

o BARIUM ENEMA (+/- air contrast): demonstrates the presence of diverticulae with a saw-tooth appearance of lumen, reflecting pseudohypertrophy of circular muscle (see photo).

o FLEXIBLE SIGMOIDOSCOPY/COLONOSCOPY: diverticulae can be seen and other pathology can be excluded

o CT SCAN: in ACUTE setting for diagnosis and identification of complications.

Question 19

Barium enema for acute investigation of diverticular disease?

Answer 19

Should not be performed in acute setting as there is a danger of perforation.

Question 20

How should diverticulosis be managed? (x4)

Answer 20

Soluble high-fibre diet, high Vitamin D, probiotics and anti-inflammatories (mesalazine). The latter two prevent flares of diverticulitis.

Question 21

How is diverticular disease managed when there is GI bleed? (x3 and x1)

Answer 21

Conservatively with IV rehydration, antibiotics, and blood transfusion if necessary. Angiography and embolization or surgery if severe.

Question 22

How is diverticulitis managed? (x4)

Answer 22

IV antibiotics, fluid rehydration and bowel rest. Localised collections or abscesses may be treated by radiologically sited drains or antibiotics.

Question 23

When is surgery indicated in diverticular disease?

Answer 23

Recurrent attacks or when complications develop such as perforation, generalised purulent peritonitis, and generalised faecal peritonitis.

Question 24

How is diverticular disease surgically managed? (x2 and x3)

Answer 24

OPEN: Hartmann’s procedure (resection and stoma) or one-stage resection and anastomosis +/- defunctioning stoma. OR LAPAROSCOPIC: drainage, peritoneal lavage and drain placement.

Question 25

What is the risk of one-stage resection and anastomosis in diverticular disease management?

Answer 25

Leakage.

Question 26

What is the prognosis of diverticular disease: recurrence?

Answer 26

10-25% will have one or more episodes of diverticulitis. Of these, 30% will have a second episode.

Question 27

What are the complications that arise from diverticular obstruction by inspissated faeces?

Answer 27

Inspissated means congealed/thickened. Complications: bacterial overgrowth, toxin production, mucosal injury, diverticulitis, abscess, ulceration, fistula, stricture formation.