Diverticular disease Flashcards
What is a diverticulum
Outpouching of the bowel wall. They are most commonly found in the sigmoid colon
What is diverticulosis
Presence of diverticula(asymptomatic)
What is diverticulitis
Inflammation and infection of the diverticula
What is diverticular disease
It consists of herniation of colonic mucosa through the muscular wall of the colon.
The usual site is between the taenia coli where vessels pierce the muscle to supply the mucosa. For this reason, the rectum, which lacks taenia, is often spared.
What is a diverticular bleed
Where the diverticulum erodes into a vessel and causes a large volume painless bleed
What can happen in chronic diverticulitis
Fistulae can form, most commonly colovesical or colovaginal
Definition of complicated diverticulitis
Abscess presence or free perforation, whilst simple diverticulitis describes inflammation without these features
Risk factors for formation of diverticulum
Age Low dietary fibre intake Obesity Smoking Family history NSAID use
Features of diverticular disease
Intermittent lower abdominal pain
Typically colicky in nature and may be relieved by defecation
Altered bowel habit
Associated nausea and flatulence
Presentation of acute diverticulitis
Acute abdominal pain(typically sharp in nature and normally localised in left iliac fossa, worsened by movement)
Localised tenderness
Features of systemic upset such as decreased appetite, pyrexia, or nausea
Change in bowel habit - constipation more common but diarrhoea also reported
Urinary frequency, urgency or dysuria
PR bleeding
What can sometimes mask symptoms of diverticulitis
Corticosteroids or immunosuppressants(even if perforated)
Investigation of choice for suspected diverticulitis
CT abdomen-pelvis scan
- Thickening of colonic wall, pericolonic fat stranding, abscesses, localised air bubbles, or free air
Staging classification for diverticulitis
Hinchey classification
Management of uncomplicated diverticular disease
Simple analgesia
Oral fluid intake
Outpatient colonoscopy to exclude any masked malignancies
Management of diverticular bleeds
Most cases self-limiting
Any significant bleeding will need appropriate resuscitation including blood products and stabilisation
Failure of conservative management may warrant embolisation or surgical resection
Management of acute diverticulitis
Can be managed conservatively with antibiotics, iv fluids and analgesia
Surgical management of acute diverticulitis
Usually hartmann’s procedure(sigmoid colectomy with formation of an end colostomy)
An anastomosis with reversal of colostomy may be possible at a later date
Complications of diverticulitis
Recurrence
Strictures
Fistulae
How might a diverticular stricture present
Large bowel obstruction
In such cases, a sigmoid colectomy is required
How do colovesical fistulae present
Form between bowl and the bladder
Present with recurrent UTIs, pneumoturia(gas bubbles in urine), or passing faecal matter in urine
How do colovaginal fistulae present
Form between the bowel and the vagina
Generally present with copious vaginal discharge or recurrent vaginal infections
What are diverticula thought to be due to
due to increased intra-colonic pressure and usually occur along the weaker areas of the wall such as where the penetrating arteries enter the colonic wall
What features of diverticulitis may indicate a fistula
Symptoms such as pneumaturia or faecaluria may suggest colovesical fistula while vaginal passage of faeces or flatus may suggest a colovaginal fistula.
Bowel sounds in diverticulitis
Possibly reduced bowel sounds
What might a lack of improvement with treatment of diverticulitis indicate
Abscess
Why should a colonoscopy be avoided initially in diverticulitis
should be avoided initially due to increased risk of perforation in diverticulitis
Complications of diverticular disease
Diverticulitis Haemorrhage Development of fistula Perforation and faecal peritonitis Perforation and development of abscess Development of diverticular phlegmon
When is segmental resection indicated for diverticular disease
Recurrent episodes of acute diverticulitis
Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.
Hinchey classification I
Para-colonic abscess
Hinchey classification II
Pelvic abscess
Hinchey classification IIII
Purulent peritonitis
Hinchey classification IV
Faecal peritonitis
Initial step in suspected diverticular disease
Arrange a routine referral to a specialist in colorectal surgery to confirm the diagnosis.
Specialist investigations may include colonoscopy or computed tomography (CT) colonography to confirm the presence of diverticula.
When should urgent admission be arrange in suspected diverticular disease
if a person has diverticular disease with significant rectal bleeding (for example, if the person is haemodynamically unstable), as urgent blood transfusion may be required.
General advice for mx of diverticular disease if admission not needed
Provide sources of info(Gut and liver disease charity Guts UK)
Recommend eating a healthy, balanced diet containing whole grains, fruits, and vegetables. Increase fibre(benefits may take a while but intake should be maintained for life)
Adequate fluids
Consider bulk-forming laxative if high-fibre diet is insufficient
Analgesia(paracetamol, avoid NSAIDs)
Re-review in month
Abx in suspected infection in diverticulitis
Co-amoxiclav
Advice regarding diet in acute diverticulitis
Recommend clear liquids only, with a gradual reintroduction of solid food if symptoms improve over the following 2–3 days.
