Diverticular Disease

Question 1

What is a diverticulum?

Answer 1

Outpouching of gut wall

Question 2

What is Diverticulosis?

Answer 2

Presence of diverticula (asymptomatic)

Question 3

What is diverticular disease?

Answer 3

Symptoms arising from diverticula

Question 4

What is Diverticulitis?

Answer 4

Inflamm. of diverticulum

Question 5

What is the pathophysiology of a diverticulum? (3 steps)

Answer 5

1. Naturally weakened bowel over time
2. Movement of stool –> increases luminal pressure
3. Outpouching of mucosa @ weaker areas

Question 6

What is the pathophysiology of diverticulitis?

Answer 6

Bacteria grows in diverticula –> inflam

Question 7

How are diverticulitis classified?

Answer 7

Simple vs Complicated

Question 8

What makes a diverticulitis a Complicated diverticulitis? (2 things)

Answer 8

1. Abscess
2. Perforation

Question 9

What are the risk factors for developing a diverticulum? (6 things)

Answer 9

1. Age
2. FHx
3. Obesity
4. Smoking
5. NSAIDs
6. Low fibre intake

Question 10

What are the clinical features of Diverticular disease? (4 things)

Answer 10

1. Nausea
2. LIF pain (colicky, relieved by defecation)
3. Alt bowel habits
4. Flatulence (farting)

Question 11

What are the clinical features of Diverticulitis ? (8 things)

Answer 11

1. Fever
2. Nausea
3. LOA
4. Tachycardia
5. LIF pain (SHARP, worse on movement)
6. Localised tenderness
7. Guarding + rigidity (suggests complicated: absc + perf)
8. Reduced bowel sounds

Question 12

How will a perforated diverticulum present?

Answer 12

Localised peritonism / generalised peritonitis

Very unwell, maybe fatal

Question 13

What can mask the symptoms of diverticulitis, even if its perforated?

Answer 13

If patient taking corticosteroids / immunosuppressants

Question 14

What are other differentials of suspected diverticular diseases? (5 things)

Answer 14

Lower abdominal pain + bowel symptoms

1. Inflamm bowel disease
2. Bowel cancer

Abdominal pain

3. Mesenteric ischaemia
4. Gynae causes
5. Renal stones

Question 15

What lab tests should be done for suspected diverticular diseases? (4 things)

Answer 15

1. FBC (raised WCC)
2. CRP (raised)
3. U&Es
4. Faecal calprotectin (if diagnosis not clear)

Question 16

In addition to routine blood tests, what other lab tests should be done especially for suspected diverticulitis? (2 things)

Answer 16

1. Group & Save
2. Urine dipstick (exclude urological causes)

Question 17

What is the best scan for suspected diverticulitis?

Answer 17

CT abdomen-pelvis

Question 18

What may a CT abdomen-pelvis of suspected diverticulitis show? (4 things)

Answer 18

1. Thickened colon wall
2. Pericolonic fat stranding (fasc inf of mesentry in pic)
3. Abscesses
4. Localised air bubbles / free air

Question 19

Why should a colonoscopy NOT be done for suspected diverticulitis?

Answer 19

Risk of perforation

Question 20

What scans should be done for suspected diverticulitis? (3 things)

Answer 20

1. CT: best for abscesses
2. Erect CXR: pneumoperitoneum in perforation
3. AXR: dilated bowel loops / obstruction / abscesses

Question 21

What is the staging system for acute diverticulitis?

Answer 21

Hinchey Classification

Question 22

What are the stages of Hinchey Classification for acute diverticulitis? (4 stages)

Answer 22

Stage 1a: Phlegmon (inflamm w no liquid / pus)
Stage 1b: Pericolic / Mesenteric abscess
Stage 2: Walled off pelvic abscess
Stage 3: Generalised purulent (pus) peritonitis
Stage 4: Generalised faecal peritonitis

Question 23

What is a phlegmon?

Answer 23

Inflamm of soft tissue w NO liquid / pus

Question 24

How do you manage a patient with uncomplicated diverticular disease? (4 things)

Answer 24

1. As outpatient
2. Simple analgesia
3. Encourage oral fluid intake
4. Outpatient colonoscopy (to exclude any masked malignancies)

Question 25

How do you manage a patient with diverticular bleeds? (3 things)

Answer 25

1. Conservatively, most will be self-limiting 2. Significant bleeding --\> resuscitation with blood products + stabilisation 3. Failed conservative --\> embolisation / surgical resection

Question 26

When should you admit a patient with (uncomplicated) diverticular disease into hospital? (5 things)

Answer 26

1. Uncontrolled pain 2. Dehydration concerns 3. Significant co-morbidities / immunocompromised 4. Significant PR bleeding 5. Symptoms 48 hours + despite conserv. management

Question 27

How do you manage a patient with acute diverticulitis? (3 things)

Answer 27

Conservatively 1. Abx 2. IV fluids 3. Analgesia

Question 28

When is surgical intervention indicated for acute diverticulitis? (2 things)

Answer 28

Perforation with: 1. Faecal peritonitis (Hinchey Classification Stage 4) 2. Sepsis

Question 29

What is the surgical procedure for acute diverticulitis?

Answer 29

Hartmanns Procedure | (Sigmoid colectomy w. formation of end colostomy)

Question 30

What are the complications of diverticulitis?

Answer 30

1. Perforation --\> peritonitis / sepsis / death 2. Diverticular stricture 3. Fistula (colovesical (bowel n bladder) / colovaginal (bowel n vagina)) 4. Haemorrhage 5. Abscess

Question 31

How do you manage a haemorrhage of acute diverticulitis? (2 things)

Answer 31

1. Colonoscopic haemostasis 2. Embolization / colonic resection (if haemostasis not successful)

Question 32

How do you manage a fistula of acute diverticulitis?

Answer 32

1. Colonic resection (surgery)

Question 33

What are the features of an abscess of acute diverticulitis? (3 things)

Answer 33

1. Swinging fever 2. Leucocytosis 3. Rectal mass

Question 34

How do you manage an abscess of acute diverticulitis? (2 things)

Answer 34

1. Abx 2. US / CT guided drainage