Diverticular Disease Flashcards
what is diverticulosis
presence of diverticulae, outpouchings of the mucosal and submucosal colon through the muscular wall of the large bowel
what is diverticular disease
diverticulosis associated with complications. for example haemorrhage, infection or fistulae
what is diverticulitis
acute inflammation and infection of the colonic diverticulae
what is the Hinchley classification of diverticulitis
Ia- phlegmons
Ib and II- localised abscesses
III- perforated abscesses
IV- faecal peritonitis
what is a phlegmon and what is the difference with an abscess
phlegm’s are purulent inflammatory processes characterised by tissue necrosis
abscesses are localised whereas phlegmons can keep spreading along the muscular fibre, unbounded
aetiology of diverticular disease
low-fibre diet leads to loss of stool bulk, this leads to high colonic intraluminal pressure to propel stool which causes herniation of the colonic submucosa and mucosa through the muscularis
summarise pathogenesis of diverticular disease
diverticulae are most likely to be found on the sigmoid colon and descending (LEFT SIDES) but can also be found on the right
diverticulae will not be found in the rectum
what sites are diverticulae usually found at
sites of nutrient artery perforation
what may diverticular obstruction lead to
obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury. this can then lead to diverticulitis, perforation, ulceration or stricture formation
epidemiology
very common,
rare below the age of 40,
60% of people living in industrialised areas will develop diverticular disease
risk factors for diverticular disease
age above 50,
low fibre diet,
diet rich in meat, sugar and salt,
BMI above 30 (obesity)
how does diverticular disease present
often asymptomatic (80-90%)
LLQ pain, guarding and tenderness
bloating
constipation
what symptoms can complications lead to
PR bleeding, diverticulitis (acute inflammation associated with LIF pain, fever), diverticular fistulation (faecaluria, pneumaturia, UTI)
why can there never be urine in the faeces but can have faeces in the urine
bladder has a lower pressure than the rectum so down a pressure gradient, faeces can pass into urine
signs of diverticular disease on physical examination
diverticulitis will show a tender abdomen and signs of general/local peritonitis if a divertulae has perforated
what investigations will be carried out
bloods, barium enema and flexible sigmoidoscopy and colonoscopy
what bloods will be ordered and what will you expect to see
high WCC and CRP. check for clotting and cross-match if bleeding
why will a barium enema not be done in an acute setting
hazardous and increases the risk of perforation and therefore will not be performed in an acute setting
why is a flexible sigmoidoscopy and colonoscopy significant/ relevant
diverticulae can be seen and therefore other pathology such as tumours and polyps can be excluded
in an acute setting what investigation will be done
CT as it shows evidence for diverticular disease as well as complications
management plan of diverticular disease if patient is asymptomatic
high fibre diet (20-30g per day), probiotics and inflammatories to prevent diverticulitis flare ups
management of GI bleeds
conservative management with IV fluids to rehydrate, antibiotics and if necessary, a blood transfusion should be performed. if severe angiography and embolisation or surgery
what is angiography with embolisation
method to manage and treat GI bleeds. its a minimally invasive procedure to block blood vessels in an aim to stop bleeding
management of diverticulitis
IV ABx, IV fluids, bowel rest, abscessed may be drained using radiologically sited drains
when is surgery available to those with diverticular disease
if the patients have recurrent attacks (flare ups) or complications such as peritonitis or perforation
what surgery will be done
- laparoscopic (keyhole) drainage, peritoneal lavage and drain placement
- open surgery (Hartmanns procedure or one step resection) and anastomosis
what is anastomosis and what is the risks involved
surgical connection between two structures. It usually means a connection that is created between tubular structures, such as blood vessels or loops of intestine.
carries a risk of leakage
possible complications of diverticular disease
perforation, faecal peritonitis, pericoli abscess, diverticulitis, colonic obstruction, fistula formation (bladder vagina and small bowel) and haemorrhages
what symptoms are obstructions consistent with
colicky pain and change in bowel habit.
perforations result in SUDDEN acute onset of persistent pain
prognosis
10-25% will have one or more episodes of diverticulitis
