DIVERTICULAR DISEASE Flashcards
What are diverticula?
sac-like protrusions of mucosa through the muscular wall of the colon.
Where do most diverticula occur?
In sigmoid and descending colons in 85%
What group of people are more likely to have a diverticula on the right/ascending colon?
Asian origin
What proportion of adults over 50 have diverticula?
50%
What is diverticulosis?
The presence of diverticula without symptoms
What is diverticulitis?
Diverticula that are inflamed and may be caused by infection
What is diverticular disease?
Condition where diverticula cause symptoms
What symptoms may diverticular disease present with?
Intermittent lower abdominal pain (commonly LLQ), bloating, erratic bowel habits
In severe cases, severe pain and constipation can occur from luminal narrowing
Without inflammation and infection!!!
What symptoms may be present in diverticulitis?
Severe lower abdominal pain LIF
Fever
Constipation
Tachycardia
General malaise
Diarrhoea
Rectal bleeding
What is u7ncomplicated diverticulitis?
diverticular inflammation without symptoms of acute abdomen, or signs of perforation or abscess formation.
What is complicated diverticulitis?
iverticulitis associated with complications, such as abscess, peritonitis, fistula, obstruction, or perforation.
Whats the pathophysuology of diverticular disease?
Low fibre diet = lower stool bulk = slower transit times = increases intraluminal pressure = promotes herniation of mucosa through relatively weak areas where vasa recti penetrate colonic wall
What are the risk factors for diverticular disease?
Low fibre diet
Old age
Genetic 40-50%
Diet rich in red meat
Smoking
Obesity
NSAID use
Immunosuppression
What are the complications of diverticulitis?
Diverticular haemorrhage
Intra-abdominal abscess formation
Perforation
Peritonitis
Stricture and fistula formation
Intestinal obstruction from above due to recurrent inflammation
Sepsis
What causes diverticulitis?
faeces obstruct the neck of the diverticulum, causing stagnation and allowing bacteria to multiply and produce inflammation.
What proportion of diverticular disease is asymptomatic?
95% of cases
How is diverticular disease diagnosed?
Often discovered incidentally on colonoscopy or barium enema examination
(Colonoscopy or virtual colonoscopy is investigation of choice)
How do you manage those with diverticulosis ?
No treatment other than advice to increase dietary fibre is required. Advise on drinking adequate fluid when having a high fibre diet
May consider offering bulk-forming laxative for people with constipation
How should you assess someone with suspected diverticular disease?
Medical history
Abdominal examination
Pelvic exam and PR exam
FBC, FOB/FIT test, U&E, eGFR, urinanalysis, CRP, ESR
Colonoscopy/other imaging
How do you manage diverticular disease?
If significant rectal bleeding then urgent admission for blood transfusion
Advise on avoiding NSAIDs, opioid analgesia, diet, lifestyle, fluid, smoking, weight loss, exercise
Consider offering:
Bulk forming laxative
Simple analgesia for ongoing abdo pain
Antispasmodic for abdominal cramping
In very severe cases, surgery may be required to remove the area
Whats an example of an anti-spasmodic?
Mebeverine hydrochloride
Whats the moa of mebeverine?
Anticholinergic - works directly on smooth muscle in GIT - prevents muscle spasm without affecting normal gut motility
What are the indications of mebeverine?
Adjunct in GIT disorders characterised by smooth muscle spasm
IBS
Whats the contraindication of mebeverine?
Paralytic ileus
How should you manage acute diverticulitis?
If symptoms are severe, or over 65 or risk of dehydration or significant comorbidity then arrange same-day hopsital assessment
If systemically unwell… Oral antibiotic - coamoxiclav
If systemically well … simple analgesia
Provide advice on diet, lifestyle, course, complications, symptoms, when to seek medical advice, risks of treatments etc
Reassess if symptoms persist or they deteriorate
What will you see on CT colonography in diverticular disease?
Colonic wall thickening
Diverticular
Pericolic collections and abscesses
What are true diverticula?
When diverticula include all the layers from mucosa to serosa
What are pseudodivertiucla?
mucosal or submucosal protrusions through the muscular wall of the bowel.
Are true or false diverticula more common in the large intestine?
False
Where do most diverticula form and why?
Sigmoid colon
La place’s law says pressure eon the wall of a cylinder is inversely proportional to its diameter i.e. as diameter decreases pressure increases
The sigmoid colon has the smallest diameter so its subject to the highest pressures
What genetic conditions can cause diverticula?
Marfan syndrome and ehlers danlos - connective tissue disorders
Without connective tissue supporting colon wall, diverticula are more likely to form
Why is diverticulitis not commonly associated with haematochezia?
Because blood vessels tend to be scarred from the inflammation
What are typical fistulas to form secondary to diverticula?
Colovesicular fistula - fistula between colon and bladder - can cause air (pneumaturia) and stool (fecaluria) in urine
What is meckels diverticulum?
an outpouching or bulge in the lower part of the small intestine
A congenital defect
A true diverticulum
What 2 fistulas can form as a result of diverticular disease and how do they present?
Colovesical fistula - pneumaturia or faecaluria
Colovaginal fistula - vaginal passage of faces or flatus
