Diverticular Disease

Question 1

What is a diverticulum?

Answer 1

Outpouching of the bowel wall

Most commonly found in the sigmoid colon but can be present anywhere

Question 2

What are the 4 different manifestations of the diverticulum?

Answer 2

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

Question 3

What is the pathophysiology of diverticular disease?

Answer 3

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)

Question 4

What can are complications of diverticulitis?

Answer 4

Perforation - diffuse sepsis and death

Fistulae formation - colovesical, colovaginal

Question 5

What are the classifications of diverticulitis?

Answer 5

Simple - without complicated features

Complicated - abscess presence or free perforation

Question 6

What are the risk factors of diverticulum formation?

Answer 6

Increasing Age 
Low dietary fibre intake 
Obesity 
Smoking 
FH 
NSAID use
Male

Question 7

What are the clinical features of diverticulosis?

Answer 7

Large amount remain asymptomatic and are found incidentally

Question 8

What are the features of diverticular disease?

Answer 8

Intermittent lower abdominal pain - colicky in nature and maybe be relieved by defecation.

Other symptoms - altered bowel habits, nausea and flatulence

No systemic symptoms

Question 9

What are the clinical features of acute diverticulitis?

Answer 9

Acute abdominal pain - sharp, left iliac fossa, worsened by movement

Localised tenderness

Systemic upset - decreased appetite, pyrexia or nausea

Question 10

What are the signs of perforated diverticulum?

Answer 10

Signs of localised peritonism or generalised peritonitis

Very unwell

Question 11

Where may pain be in pts with redundant sigmoid colon?

Answer 11

Right lower quadrant

Supra pubic area

Question 12

What may mask symptoms of diverticulitis even when perforated?

Answer 12

Corticosteroids or immunosuppressants

Question 13

What is a diverticular abscess and what is its management?

Answer 13

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

Question 14

What is the differential diagnosis for diverticular disease?

Answer 14

IBD
Bowel cancer

Mesenteric ischaemia
Gynaecological causes
Renal stones

Question 15

What investigations should be requested for diverticular disease?

Answer 15

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

Question 16

What classification is used based on CT findings for diverticular disease?

Answer 16

Hinchey classification

Question 17

What are the stage of Hinchey classification?

Answer 17

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

Question 18

How should pts with uncomplicated diverticular disease be managed?

Answer 18

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.

Question 19

What is the management of diverticular bleeds?

Answer 19

Conservatively as self limiting but resuscitation may be required if significant blood loss + blood products

Question 20

What if conservative management fails in diverticular bleeds?

Answer 20

Embolisation

Or surgical resection

Question 21

What is the management of acute diverticulitis?

Answer 21

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

Question 22

When is surgical management required in diverticular disease?

Answer 22

Perforation of faecal peritonitis or overwhelming sepsis

Question 23

What is the surgical management for diverticular disease?

Answer 23

Hartman’s procedure

Reversal of colostomy at later date may be possible

Question 24

What are the complications of diverticular disease?

Answer 24

Reccurance - segmental resection may be performed

In severe, recurrent or chronic cases - stricture or fistula formation

Question 25

What may be seen on a CT of diverticular disease?

Answer 25

Thickening of colonic wall 
Pericolonic fat stranding 
Abscess 
Localised air bubbles 
Free air

Question 26

What are the two fistulas that can form in diverticular disease and how may they present ?

Answer 26

Colovesical - recurrent UTI, pneumouria, faecal matter in urine

Colovaginal - copious vaginal discharge to recurrent vaginal infections

Enterocolic

Question 27

What can result from diverticular stricture and what is the treatment?

Answer 27

Large bowel obstruction

Sigmoid colectomy or colonic stenting as a temporary measure

Question 28

How can mild attacks of diverticulitis be treated at home?

Answer 28

Bowel rest (fluids only) +/- antibiotics

Question 29

What is important if you suspect abscess but it is not localised?

Answer 29

Pus somewhere, pus nowhere = pus under the diaphragm

Sub-phrenic abscess - urgent ultrasound. Antibiotics +/- drainage