Diverticular disease Flashcards
What is diverticular disease?
Herniation of colonic mucosa through the muscular wall of the colon
Pathophysiology of diverticular disease
- Bowel weakens with age
- Movement of stool within lumen causes an ↑ in luminal pressure
- Results in outpouchings of mucosa through weaker areas of the bowel wall
- Bacteria overgrow within outpouchings, leading to diverticulitis
Which area of the intestine does diverticular disease affect?
Sigmoid - between the taenia coli
The rectum (lacks taenia) is often spared
How does diverticular disease present?
- Constipation
- Left lower quadrant pain (colicky, relieved by defecation)
- Some patients experience rectal bleeding
Imaging investigations for diverticular disease
colonoscopy, CT cologram or barium enema
List 4 risk factors for diverticular disease
- Increased age
- Low fibre diets
- obesity
- use of NSAIDs
How is diverticular disease diagnosed?
Colonoscopy or CT scans (often incidentally)
Examination findings of diverticular disease?
- May be normal
- May be tenderness in the left lower quadrant
- May be tenderness on digital rectal examination
Treatment if diverticular disease?
- High fibre diet and weight loss
- Bulk-forming laxatives (eg. ispaghula husk)
- Weight loss
If severe, surgery to remove affected area may be required
List 2 common complications of diverticular disease?
- Strictures - due to repeated episodes of inflammation
- Fistulas (Colovesical and Colovaginal)
What is Diverticulitis?
Inflammation in the diverticula
How does diverticulitis present?
- Pain and tenderness in left iliac fossa
- Fever
- Diarrhoea
- Nausea and vomiting
- Rectal bleeding
- Palpable abdominal mass (if abscess)
- Raised inflammatory markers (CRP) and WBCs
List 4 signs of diverticulitis
- Low grade pyrexia
- Tachycardia
- Tender LIF
- Guarding, rigidity and rebound tenderness (complicated)
First line imaging for diverticulitis?
List 3 changes which may be seen
CT abdomen-pelvis:
- Thickening of colonic wall
- Pericolonic fat stranding
- Abscesses
- localised air bubbles or free air
Are Colonoscopy’s used in patients presenting with suspected diverticular disease?
NO, due to increased risk of perforation
Compare complicated with uncomplicated diverticulitis
Uncomplicated: localised inflammation that does not extend to the peritoneum
Complicated: associated with complications ie. rectal bleeding, abscess, peritonitis, fistula, obstruction, or perforation
Management of uncomplicated diverticulitis in primary care?
- Oral co-amoxiclav (at least 5 days)
- Analgesia (avoid NSAIDs and opiates)
- Clear liquids onlyuntil symptoms improve
- Follow-up within 2 days to review symptoms
Management of complicated diverticulitis in hospital?
- Nil by mouth or clear fluids only
- IV antibiotics and fluids
- Analgesia
- Urgent investigations (eg. CT scan)
- Urgent surgery may be required for complications
When may surgery be required for acute diverticulitis?
- Perforation with faecal peritonitis
- Overwhelming sepsis
What is the name of the most common surgical procedure performed for diverticulitis?
Hartmann’s procedure
Sigmoid colectomy with formation of an end colostomy (anastomosis with reversal of colostomy may be possible at a later date).
List 4 complications of diverticulitis
- Perforation
- Peritonitis
- Peridiverticular abscess
- Large haemorrhage
- Fistula
- Ileus / obstruction
What classification systemic is used for acute diverticulitis?
Hinchey
How will a perforated diverticulum present?
Signs of localised peritonism or generalised peritonitis
Patient will be extremely unwell, can often be fatal
Management of a Peridiverticular abscess?
< 5 cm IV antibiotics. If any bigger, radiological drainage is first-line
Complicated multi-loculated abscesses require a laparoscopic washout or Hartmann’s procedure
What can mask the symptoms of diverticulitis, even if its perforated?
If patient is taking corticosteroids / immunosuppressants
