Diverticular disease

Question 1

What is a diverticulum

Answer 1

Outpouching of the bowel wall. They are most commonly found in the sigmoid colon

Question 2

What is diverticulosis

Answer 2

Presence of diverticula(asymptomatic)

Question 3

What is diverticulitis

Answer 3

Inflammation and infection of the diverticula

Question 4

What is diverticular disease

Answer 4

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.

Question 5

What is a diverticular bleed

Answer 5

Where the diverticulum erodes into a vessel and causes a large volume painless bleed

Question 6

What can happen in chronic diverticulitis

Answer 6

Fistulae can form, most commonly colovesical or colovaginal

Question 7

Definition of complicated diverticulitis

Answer 7

Abscess presence or free perforation, whilst simple diverticulitis describes inflammation without these features

Question 8

Risk factors for formation of diverticulum

Answer 8

Age 
Low dietary fibre intake 
Obesity 
Smoking 
Family history 
NSAID use

Question 9

Features of diverticular disease

Answer 9

Intermittent lower abdominal pain
Typically colicky in nature and may be relieved by defecation
Altered bowel habit
Associated nausea and flatulence

Question 10

Presentation of acute diverticulitis

Answer 10

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

Question 11

What can sometimes mask symptoms of diverticulitis

Answer 11

Corticosteroids or immunosuppressants(even if perforated)

Question 12

Investigation of choice for suspected diverticulitis

Answer 12

CT abdomen-pelvis scan

• Thickening of colonic wall, pericolonic fat stranding, abscesses, localised air bubbles, or free air

Question 13

Staging classification for diverticulitis

Answer 13

Hinchey classification

Question 14

Management of uncomplicated diverticular disease

Answer 14

Simple analgesia
Oral fluid intake
Outpatient colonoscopy to exclude any masked malignancies

Question 15

Management of diverticular bleeds

Answer 15

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

Question 16

Management of acute diverticulitis

Answer 16

Can be managed conservatively with antibiotics, iv fluids and analgesia

Question 17

Surgical management of acute diverticulitis

Answer 17

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

Question 18

Complications of diverticulitis

Answer 18

Recurrence
Strictures
Fistulae

Question 19

How might a diverticular stricture present

Answer 19

Large bowel obstruction

In such cases, a sigmoid colectomy is required

Question 20

How do colovesical fistulae present

Answer 20

Form between bowl and the bladder

Present with recurrent UTIs, pneumoturia(gas bubbles in urine), or passing faecal matter in urine

Question 21

How do colovaginal fistulae present

Answer 21

Form between the bowel and the vagina

Generally present with copious vaginal discharge or recurrent vaginal infections

Question 22

What are diverticula thought to be due to

Answer 22

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

Question 23

What features of diverticulitis may indicate a fistula

Answer 23

Symptoms such as pneumaturia or faecaluria may suggest colovesical fistula while vaginal passage of faeces or flatus may suggest a colovaginal fistula.

Question 24

Bowel sounds in diverticulitis

Answer 24

Possibly reduced bowel sounds

Question 25

What might a lack of improvement with treatment of diverticulitis indicate

Answer 25

Abscess

Question 26

Why should a colonoscopy be avoided initially in diverticulitis

Answer 26

should be avoided initially due to increased risk of perforation in diverticulitis

Question 27

Complications of diverticular disease

Answer 27

Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon

Question 28

When is segmental resection indicated for diverticular disease

Answer 28

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.

Question 29

Hinchey classification I

Answer 29

Para-colonic abscess

Question 30

Hinchey classification II

Answer 30

Pelvic abscess

Question 31

Hinchey classification IIII

Answer 31

Purulent peritonitis

Question 32

Hinchey classification IV

Answer 32

Faecal peritonitis

Question 33

Initial step in suspected diverticular disease

Answer 33

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.

Question 34

When should urgent admission be arrange in suspected diverticular disease

Answer 34

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.

Question 35

General advice for mx of diverticular disease if admission not needed

Answer 35

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

Question 36

Abx in suspected infection in diverticulitis

Answer 36

Co-amoxiclav

Question 37

Advice regarding diet in acute diverticulitis

Answer 37

Recommend clear liquids only, with a gradual reintroduction of solid food if symptoms improve over the following 2–3 days.