Diverticular disease

Question 1

Pathophysiology of colonic diverticulosis

Answer 1

Increased intraluminal pressure due to:

1) low fibre diet
2) weakness of muscular wall (usually where vessels traverse)

Question 2

How common is diverticular disease?

Answer 2

10% < 40 years
50% >50 years
70% at 80 years

Question 3

Potential complications of diverticular disease

Answer 3

inflammation
abscess
perforation
fistulation
stricture

Question 4

Hinchey Stage 1

Answer 4

Pericolic abscess

Question 5

Hinchey Stage 2

Answer 5

Pelvic abscess

Question 6

Hinchey Stage 3

Answer 6

Generalised purulent peritonitis

Question 7

Hinchey Stage 4

Answer 7

Fecal peritonitis

Question 8

Treatment according to Hinchey staging

Answer 8

Stage 1 and 2: IV antibiotics and drainage
Stage 3: laparoscopic lavage /primary resection/ Hartmann
Stage 4: resection

Question 9

Potential drawbacks of laparoscopic lavage

Answer 9

Missing pathology (persistent perforation, concealed fecal peritonitis), perforated sigmoid cancer, subsequent fistula

Question 10

Risk factors for diverticulosis

Answer 10

Age
Low fibre diet
Westernised lifestyle
Family History

Question 11

Risk factors for diverticulitis

Answer 11

Obese young male

Immunosuppresion

Question 12

Commonest site of diverticulosis

Answer 12

Sigmoid, then caecum

Question 13

Classifications for diverticulitis

Answer 13

Hinchey
Kohler
Modified Hinchey
Hansen/Stock

Question 14

Discussion points for colonoscopy after diverticulitis

Answer 14

Most guidelines suggest colonic evaluation if no prior CLN, to be done more than 6 weeks after episode

• average risk of CRC 0.3%
• opportunistic screening
• advancement of CT
• any history of colonoscopy
• diverticulitis not a risk factor for CRC

Question 15

Are antibiotics necessary for uncomplicated diverticulitis?

Answer 15

Despite lack of high quality evidence, general practice is selective use of antibiotics

However recent studies:
-AVOD Swedish trial:
-DIABOLO
no difference w + w/o antibiotics
BUT many pt in trial did not meet criteria for inpatient tx

Question 16

Modified Hinchey
Stage 0
Stage I
Stage Ia
Stage Ib
Stage II
Stage III
Stage IV

Answer 16

0: mild clinical
1: pericolic abscess/phlegmon
Ia: confined pericolic inflammation
Ib: confined small pericolic abscess
2: pelvic, intraabdominal, retroperitoneal abscess
3: generalised purulent peritonitis
4: generalised faecal peritonitis

Question 17

Evidence related to laparoscopic lavage

Answer 17

SCANDIV
LOLA
DILALA

-more frequent major complications
-similar morbidity and mortality
-lower stoma rate
Conclusion:
For selected Hinchey III patients, those too ill for resection

Question 18

Indications for elective surgery in acute complicated diverticulitis

Answer 18

• Fistula / stenosis causing obstruction
• recurrent attack
• high risk patient with prior episode of diverticulitis
• first attack inimmunocompromised patients

10-12 weeks after episode

Question 19

Options for emergency surgical resection

Answer 19

• Segmental resection/ Hartmann’s operation/mucus fistula
• Primary anastomosis +/- diverting ileostomy
• Damage control if unstable