Diverticular disease

Question 1

What is diverticulosis?

Answer 1

Presence of diverticuli (common, asymptomatic)

Tiny little pockets caused by herniation of mucosa and submucosa through muscular layer of colonic wall

Question 2

Pathophysiology of diverticulosis?

Answer 2

Unclear

Low-fibre diet increases intestinal transit time and decreases stool volume→ increased intraluminal pressure and colonic segmentation→ predispose to diverticular formation

Question 3

What is diverticulitis?

Answer 3

Inflammation of diverticuli and may be caused by infection

Question 4

Aetiology of diverticular disease?

Answer 4

Multi-factorial
- Genetic
- Environmental: low-fibre diet, decreased physical activity, obesity, increased red meat consumption, tobacco smoking, excessive alcohol and caffeine intake, steroids, NSAIDs

Other suggested aetiologies:
- Alterations in colonic wall structure
- Connective tissue abnormalities (i.e: Ehlers-Danlos syndrome)
- Infection

Question 5

Risk factors for diverticular disease?

Answer 5

• Age 50+
• Low dietary fibre
• Diet rich in salt, meat, sugar
• Obesity
• NSAID/ opioid use

Question 6

Signs and symptoms of diverticulitis? (6)

Answer 6

• LLQ pain (guarding and tenderness)
• Leukocytosis
• Fever
• May be assoc w N&V
• Bloating and constipation
• Pelvic tenderness on DRE

Uncommon: diarrhoea, rectal bleeding, diffuse tenderness

Question 7

Ix: Investigations for diverticulitis?

Answer 7

• Abdominal exam
• Bloods
• Urine dip: rule out pregnancy
• Consider abdo CT and colonoscopy

Question 8

Ix: Bloods for diverticulitis?

Answer 8

• Raised inflamm markers (Polymorphonuclear leukocytosis present in acute diverticulitis; raised CRP)
• VBG: look for lactic acidosis
• Glucose: DKA

Question 9

Main management for diverticulitis? (initial)

Answer 9

• Diet and lifestyle changes: high fibre diet, lose weight, smoking cessation
• Analgesia: ie paracetamol (avoid opiods→ constipation)
• Bowel rest (NBM)
• IV fluids
• ABs: gram negative bacteria and anaerobes e.g. co-amoxiclav and metronidazole
• Venous thromboembolism prophylaxis

Question 10

Management for PR bleeds? (May occur due to diverticulitis)

Answer 10

• IV fluids
• ABs
• Blood transfusion
• Angiography and embolisation

Question 11

Follow up after initial management of diverticulitis?

Answer 11

• Offer colonoscopy 2-6 weeks after resolution to confirm diagnosis
• Maintain diet and lifestyle changes

Question 12

When is a surgical measure necessary for diverticulitis and what does it involve?

Answer 12

Colonic resection:
2 proven episodes of acute diverticulitis requiring hospital admission/ assoc obstructive sympt/ contrast leak

Laparotomy if perforation

Question 13

Potential complications of diverticular disease? (4)

Answer 13

• Faecal peritonitis
• Haemorrhage
• Perforation
• Fistula