Diverticular Disease Flashcards
What is a diverticulum?
Outpouching of the bowel wall
Most commonly found in the sigmoid colon but can be present anywhere
What are the 4 different manifestations of the diverticulum?
Diverticulosis - the presence of diverticula (aysmptomatic - incidental finding and common)
Diverticular disease - symptoms arsing form the diverticula
Diverticulitis - inflammation of the diverticula
Diverticular bleed - where diverticulum erodes into a vessel and causes a large volume painless bleed
What is the pathophysiology of diverticular disease?
Ageing bowel naturally become weakened over time. Movement of bowel cause increased luminal pressure. Results in outpouching of the mucosa through weaker areas (triangular muscles sheets where blood vessels penetrate to supply bowel wall)
What can are complications of diverticulitis?
Perforation - diffuse sepsis and death
Fistulae formation - colovesical, colovaginal
What are the classifications of diverticulitis?
Simple - without complicated features
Complicated - abscess presence or free perforation
What are the risk factors of diverticulum formation?
Increasing Age Low dietary fibre intake Obesity Smoking FH NSAID use Male
What are the clinical features of diverticulosis?
Large amount remain asymptomatic and are found incidentally
What are the features of diverticular disease?
Intermittent lower abdominal pain - colicky in nature and maybe be relieved by defecation.
Other symptoms - altered bowel habits, nausea and flatulence
No systemic symptoms
What are the clinical features of acute diverticulitis?
Acute abdominal pain - sharp, left iliac fossa, worsened by movement
Localised tenderness
Systemic upset - decreased appetite, pyrexia or nausea
What are the signs of perforated diverticulum?
Signs of localised peritonism or generalised peritonitis
Very unwell
Where may pain be in pts with redundant sigmoid colon?
Right lower quadrant
Supra pubic area
What may mask symptoms of diverticulitis even when perforated?
Corticosteroids or immunosuppressants
What is a diverticular abscess and what is its management?
Often also known as pericolic abscess. Occurs as a sequelae in complicated diverticulitis.
<5cm - IV antibiotics
>5cm - radiological drainage
Multi-loculated or pts who clinically deteriorate - laparoscopic washout or a Hartman’s procedure
What is the differential diagnosis for diverticular disease?
IBD
Bowel cancer
Mesenteric ischaemia
Gynaecological causes
Renal stones
What investigations should be requested for diverticular disease?
Routine bloods Consider faecal calprotectin G&S VBG Urine dipstick -exclude urological cause
CT abdomen-pelvis scan
In suspected uncomplicated diverticular disease - flexible sigmoidoscopy but if not suitable then CT colongraphy
What classification is used based on CT findings for diverticular disease?
Hinchey classification
What are the stage of Hinchey classification?
Stage 1 : phegmon (1a) or diverticulitis with pericolic or mesenteric abscess (1b)
Stage 2 : diverticulitis with walled off pelvic abscess
Stage 3 : diverticulitis with generalised purulent peritonitis
Stage 4 : diverticulitis with generalised faecal peritonitis
How should pts with uncomplicated diverticular disease be managed?
Outpatient with simple analgesia an oral fluid intake. Outpatient colonoscopy arranged to exclude masked malignancies. Antispasmodics e.g. mebeverine
Should be admitted if uncontrolled pain, concerns of dehydration, significant co-morbities, immunocompromised, significant PR bleeding or symptoms persisting for longer than 48 hrs depstipe conservative management.
What is the management of diverticular bleeds?
Conservatively as self limiting but resuscitation may be required if significant blood loss + blood products
What if conservative management fails in diverticular bleeds?
Embolisation
Or surgical resection
What is the management of acute diverticulitis?
Conservative - antibiotics, IV fluids, analgesia
Young healthy pts with uncomplicated diverticulitis - ambulatory management
Symptoms improve within 2-3 days in uncomplicated.
If persist then repeat imaging to check progression/complication.
Oral intake encouraged where possible
When is surgical management required in diverticular disease?
Perforation of faecal peritonitis or overwhelming sepsis
What is the surgical management for diverticular disease?
Hartman’s procedure
Reversal of colostomy at later date may be possible
What are the complications of diverticular disease?
Reccurance - segmental resection may be performed
In severe, recurrent or chronic cases - stricture or fistula formation
What may be seen on a CT of diverticular disease?
Thickening of colonic wall Pericolonic fat stranding Abscess Localised air bubbles Free air
What are the two fistulas that can form in diverticular disease and how may they present ?
Colovesical - recurrent UTI, pneumouria, faecal matter in urine
Colovaginal - copious vaginal discharge to recurrent vaginal infections
Enterocolic
What can result from diverticular stricture and what is the treatment?
Large bowel obstruction
Sigmoid colectomy or colonic stenting as a temporary measure
How can mild attacks of diverticulitis be treated at home?
Bowel rest (fluids only) +/- antibiotics
What is important if you suspect abscess but it is not localised?
Pus somewhere, pus nowhere = pus under the diaphragm
Sub-phrenic abscess - urgent ultrasound. Antibiotics +/- drainage
