Diverticular disease

Question 1

What is diverticular disease?

Answer 1

Diverticular disease is a permanent, progressive and irreversible condition of the large bowel (or colon), in which little pockets of bowel lining bulge out through weak spots in the muscle wall. As the colon pushes motion along its length, pressure builds up inside the tube, which pushes out the lining to form these pockets. It can also cause the thickening and lengthening of the bowel.

Question 2

What % of people over the age of 50 have diverticulosis?

Answer 2

50%

Question 3

Describe the pathophysiology of diverticulum formation: (3)

Answer 3

1) points of the circular muscle in the bowel wall are penetrated by blood vessels, making these areas weaker to outpouching
2) increased pressure inside the lumen over time can cause gaps to form
3) these gaps allow mucosa to herniate through the muscle layer and pouches to form diverticula

Question 4

Why can’t diverticula form in the rectum?

Answer 4

the rectum has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support

Question 5

How many longitudinal muscle bands run across the colon?

Answer 5

3

Question 6

What is the name given to the 3 longitudinal muscle bands that run across the colon?

Answer 6

teniae coli

Question 7

What is diverticulosis?

Answer 7

the presence of diverticula without inflammation or infection

Question 8

Which section of the bowel is most commonly affected by diverticulosis?

Answer 8

Sigmoid

Question 9

Give 4 risk factors for diverticulosis:

Answer 9

1) increasing age
2) low fibre diet
3) obesity
4) use of NSAIDs

Question 10

Why should NSAIDs not be given to those with diverticulosis?

Answer 10

they increase the risk of diverticular haemorrhage

Question 11

How is diverticulosis typically diagnosed?

Answer 11

incidentally during colonoscopies or CT scans

Question 12

Give 4 clinical presentations associated with diverticulosis:

Answer 12

1) asymptomatic
2) lower left abdominal pain
3) constipation
4) rectal bleeding

Question 13

Give 3 treatments for symptomatic diverticulosis:

Answer 13

1) high fibre diet
2) bulk-forming laxatives
3) surgery if symptoms are significant

Question 14

Give an example of a bulk-forming laxative:

Answer 14

Ispaghula husk

Question 15

Give an example of a stimulant laxative:

Answer 15

Senna

Question 16

What type of laxative should be avoided in diverticular disease?

Answer 16

stimulant laxatives

Question 17

What is acute diverticulitis?

Answer 17

acute inflammation of a colonic diverticulum

Question 18

Give 6 clinical presentations associated with acute diverticulitis:

Answer 18

1) pain and tenderness in the left iliac fossa/ lower abdomen
2) fever
3) diarrhoea
4) rectal bleeding
5) palpable abdominal mass (indicates an abscess)
6) raised inflammatory markers and white cell count

Question 19

Give the 4 treatment steps for uncomplicated diverticulitis according to NICE:

Answer 19

1) oral co-amoxiclav for at least 5 days
2) analgesia (avoid NSAIDs and opiates)
3) only take clear liquids and avoid solid food until symptoms improve
4) follow up within 2 days to review symptoms

Question 20

Give the 6 steps of management for severe diverticulitis (requires hospitalisation):

Answer 20

1) nil by mouth or clear fluids only
2) IV antibiotics
3) IV fluids
4) analgesia
5) urgent investigations e.g. CT
6) urgent surgery may be required for complications

Question 21

Give 6 complications associated with diverticulitis:

Answer 21

1) perforation
2) fistula (between the colon and bladder or vagina)
3) peritonitis
4) peridiverticular abscess
5) ileus/ obstruction
6) large haemorrhage requiring blood transfusions

Question 22

What can happen if a fistula forms?

Answer 22

A diverticulum can become inflamed, and as things that are inflamed become sticky, the bowel may attach to a nearby organ (for instance, the bladder, the vagina, or another segment of the bowel). The inflamed attached pocket essentially burrows into an adjacent organ, which can allow the passage of bowel contents and wind into this organ, causing the patient to experience horrible symptoms.