Diverticular disease Flashcards
What is a diverticulum?
Sac-like protrusion of mucosa through muscular wall of the colon
Acquired or congenital.
What is diverticulosis?
Presence of diverticulae outpouchings without Sx
What is diverticular disease?
Diverticula cause Sx e.g. lower abdo pain, without inflammation or infection
What is diverticulitis?
acute inflammation +/- infection of colonic diverticulae
Complicated or uncomplicated
Distinguish between complicated and uncomplicated diverticulitis
‘Uncomplicated’: diverticular inflammation without Sx of acute abdomen, or signs of perforation or abscess formation.
‘Complicated: diverticulitis a/w complications, such as abscess, peritonitis, fistula, obstruction, or perforation.
Describe the aetiology of diverticular disease
Low-fibre diet leads to loss of stool bulk.
Requires high colonic intraluminal pressures to propel the stool out
This leads to herniation of the mucosa + submucosa through muscle layers of the gut at weak points adjacent to penetrating vessels.
At which site are diverticula most common?
Sigmoid + descending colon
Describe the prevalence of right sided diverticula
15%
More common in Asians
Describe the epidemiology of diverticular disease
VERY COMMON.
60% of HIC develop colonic diverticulae
Rare < 40y
Give 4 risk factors for diverticular disease
Low fibre diet
Increasing age
Obesity
Genetics
Describe the Hinchey Classification of Acute Diverticulitis
Ia: phlegmon: spreading diffuse inflammatory process with formation of purulent exudate
Ib + II: localised abscesses
III: perforation + purulent peritonitis
IV: faecal peritonitis: faeces in peritoneal cavity, due to LB perforation.
How may diverticulosis present?
Asymptomatic (80-90%)
Commonly an incidental finding at colonoscopy
What symptoms may arise from complications of diverticulosis?
Painless PR bleeding: Blood supply to colon is where outpouches occur so bleeds a lot
What drug may provoke bleeding in diverticulosis?
NSAIDs
What advice is given to those with diverticulosis?
Condition is asymptomatic + no specific Tx needed
Healthy balanced high fibre diet
Adequate fluid intake
Exercise, WL, smoking cessation reduce risk of diverticulitis
Give 4 S/S of diverticular disease
Intermittent abdo pain in the left lower quadrant (may be triggered by eating + relieved by passage of stool or flatus).
Bloating
Rectal bleeding
Tenderness in the LLQ on palpation
When should patients with diverticular disease be admitted?
if significant rectal bleeding (haemodynamically unstable), as urgent blood transfusion may be required.
What advice is given to those with diverticular disease?
AVOID NSAIDs + Opioids (increased risk perforation)
High fibre diet
Safety net
What medication may be offered to those with diverticular disease?
Bulk-forming laxatives if high-fibre diet not tolerated, or if constipation/ diarrhoea persist.
Paracetamol PRN
Antispasmodic (e.g. mebeverine) if abdominal cramping.
Give an example of a bulk-forming laxative
Fybogel (ispaghula husk)
Methylcellulose
Give 4 S/S of diverticulitis
Constant severe abdo pain (starts in hypogastrium before localizing to LLQ)
N+V
Fever.
CIBH + significant rectal bleeding or passage of mucus PR
List 3 signs of diverticulitis
Tachycardia
Tender LIF +/- palpable mass /distension due to inflammation/ abscess
Possibly reduced bowel sounds
What bloods are seen/ taken in diverticular disease/ diverticulitis?
Increased WCC
Increased CRP
Check clotting + cross-match if bleeding
What investigation should be performed in the acute setting in diverticulitis?
Contrast CT: evidence of diverticular disease + complications
Colonic outpouchings, bowel wall thickening > 3 mm + peridiverticular mesenteric
fat stranding
(MRI if CT CI)
Why should Barium enema or colonoscopy not be performed in the acute setting of diverticulitis?
High risk of perforation
When may an abdominal x-ray be indicated in diverticulitis?
Suspected perforation or bowel obstruction
OR
As part of routine workup for acute abdominal pain
What may be seen on AXR in complicated diverticulitis?
Bowel perforation: pneumoperitoneum
Bowel obstruction: dilated bowel loops + multiple air-fluid levels
What investigation is performed 6-8w after presentation with diverticulitis?
Colonoscopy / CT colonography to r/o IBD/ malignancy
Describe management of complicated diverticulitis
IV Abx, fluids + analgesia
Bowel rest
+/- surgery
In what setting should acute diverticulitis be managed?
MILD: oral Abx, liquid diet + analgesia
SEVERE/ If Sx don’t settle within 72h: Admit for IV Abx
What antibiotics are used in diverticulitis?
Uncomplicated: Co-amoxiclav PO
Complicated: Cefuroxime + Metronidazole IV
When is surgery indicated in diverticulitis?
If acute complicated diverticulitis (e.g. with peritonitis + sepsis)
If don’t improve with medical Tx
What surgical procedures may be performed in diverticulitis?
Percutaneous drainage of large abscesses.
Laparoscopic lavage.
Simple colostomy formation.
Sigmoid resection with colostomy (Hartmann’s procedure).
Sigmoid resection with primary anastomosis +/- a diverting stoma.
Describe the management of diverticulosis
Soluble high-fibre diet (20-30 g/day)
Some drugs may prevent recurrent flares of diverticulitis (probiotics + anti-inflammatories e.g. mesalazine)
Describe the management of a GI bleed in diverticular disease
PR bleeding usually managed conservatively with IV rehydration, Abx + blood transfusion if necessary
Angiography + embolisation or surgery if severe
When may elective surgery be considered for diverticulitis?
For recurrent complicated diverticulitis/ immunocompromised
What is the prognosis of diverticular disease?
10-25% have one or more episodes of diverticulitis
What occurs when diverticular are obstructed by thickened faeces
Bacterial overgrowth, toxin production + mucosal injury
Can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration + fistulation or stricture formation
List 7 complications of divertiuclitis
Diverticulitis
Haemorrhage
Colovesical fistula
Intra-abdominal abscess
Perforation + faecal peritonitis
Sepsis
Intestinal obstruction
List 3 signs of colovesical fistulation
Pneumaturia
Faecaluria
Pyuria
