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S - Ch. 5 - Colorectal Surgery > Diverticular Disease > Flashcards

Diverticular Disease Flashcards

1
Q

What layers are involved in Diverticular disease?
While you’re at it, state all the layers

A

Mucosal and submucosal layers => pseudodiverticula

Mucosa, submucosa, circular muscles, Auerbach plexus, longitudinal muscles, serosa including meissner’s plexus

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2
Q

Define Diverticula

A

!Acquired sac-like herniation of the mucosa and submucosa through the colonic wall

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3
Q

Define Diverticulosis

A

Presence of diverticula without inflammation!

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4
Q

Define Diverticulitis
Give 3 specific symptoms

A

Symptomatic Diverticulosis => Presence of diverticula with symptoms AKA painful Diverticulitis
Altered bowel habit of Diarrhoea and constipation (mostly) => !Pellet Like Stool!
LIF pain/discomfort
Bloating
Perforation => sepsis
Recurrent UTI (colovesical fistula)

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5
Q

Where does the herniation typically occur?
What are the most common locations for Diverticulosis? State them in descending order of prevalence.

A

Herniation typically occurs between tenia coli as it is the entry point of nutrient arterioles (puncture through wall) => Weakest point
Sigmoid colon (most common)
Sigmoid colon + Descending colon
Sigmoid + Descending + Transverse
Pancolic
Caecal

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6
Q

What is meant by true and false diverticula?

A

Colonic diverticula are typically acquired and involve no muscle layers within the wall of the colon => False
Congenital diverticula typically involve all 3 muscle layers => true
Similar to true and false aneurysm

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7
Q

Give an example of a true diverticula

A

Meckel’s diverticulum (congenital)

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8
Q

Give 7RF for Diverticular disease. total = 9

A

Age (50% over 50)
Low fibre diet
Constipation a/w straining
Obesity
Physical inactivity
Smoking
!!!Connective tissue disease: Ehler Danlos, Marfan’s (makes walls weaker as in AAA)
!!!AD polycystic kidney disease (Risk factor for bleeding as well in stroke and SAH)

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9
Q

What is the pathogenesis of Diverticular disease from low fibre diet?

A

Low fibre diet => less stool volume => increased intraluminal pressure (think vasoconstriction) => muscle hypertrophy => herniation

Also, this muscle hypertrophy leads to reduced lumen size => increased intraluminal pressure (=> viscous cycle)

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10
Q

What is the most common presentation of a patient with diverticulosis?

A

Diverticulosis = presence of diverticula without inflammation
The vast majority of patients are found incidentally during colonoscopy or barium enema => asymptomatic

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11
Q

50% of those over 50 have diverticula. 25% of which are actually symptomatic => diverticulitis. What is the typical clinical presentation of simple acute diverticulitis?

A

1) Sx of acute abdomen (Sudden abdominal pain, nausea, vomiting, altered bowel habits, tenesmus, inability to empty bowels, fever/chills, bloating/swelling and tenderness/guarding, rebound guarding, tachycardia, tachypnea

2) LIF tenderness (rarely RIF)

3) Alternating/altered bowel habit: Constipation (mostly) and Diarrhoea with !Pellet-like stool!

4) Painless Spontaneous bleeding => Hematochezia

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12
Q

State the complications of Acute Diverticulitis or Diverticular disease as a whole

A

GI haemorrhage
Obstruction/stricture formation
Abscess formation
Perforation/Peritonitis
Diverticular Fistula

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13
Q

A patient presents with simple acute diverticulitis with painless spontaneous bleeding. What is the significance of quantifying the volume?

A

Small volume = normal erosion of mural vessels by diverticulitis
Large volume = Rupture of a peri diverticular vessel

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14
Q

What is Rebound Tenderness a sign of?

A

Inflammation or irritation of the peritoneum => Peritonitis

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15
Q

What result do you expect to see on an FBC in Diverticulitis

A

Anaemia (fe-deficiency or normocytic due to haemorrhage)
WCC - raised, mostly PMN (neutrophilia)

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16
Q

What do you expect to see on a U&E in acute diverticulitis

A

Hypokalaemia

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17
Q

What imaging will you order for a patient with acute diverticulitis?

A

Erect CXR
PFA (rarely done)
CT angiography
CT abdomen and Pelvis with IV contrast

18
Q

Why would you send a request for CT angiography in the context of acute diverticulitis?

A

CT angiography to detect active bleeding, vascular compromise, perforations
Therapeutic: IR embolization in severe haemorrhage

19
Q

Why would you send a request for CT abdomen and Pelvis with IV contrast in the context of acute diverticulitis?

First class: When would you use oral or rectal contrast?

A

To screen for complications including fistula

Oral contrast best for fistulas (rarely used)

20
Q

What are the investigations you will conduct in the setting of acute diverticulitis? (rationale where applicable)

A

Bedside: ABG

Bloods: FBC (High WCC, majority neutrophils!!), U&E (Hypokalaemia), CRP, Coag, blood cultures (if systemically unwell), amylase, group and cross match 4 units

Imaging: !Erect CXR!
PFA for obstruction (rarely done)
CT abdomen with IV contrast to look for complications
CT angiography to detect active bleeding, vascular compromise +/- embolization with IR

(not included in questions) LATER: Colonoscopy 6-8 weeks later to look for complications and malignancy

21
Q

In the case of acute diverticulitis, what do you see in each phase of the CT?

A
22
Q

Although the vast majority of diverticula are found incidentally on colonoscopy or barium enema, why aren’t colonoscopies EVER done in the setting of acute diverticulitis?

What is the purpose of conducting them at a later date (state how long later as well)

A

To prevent causing bleeding and perforation. Instead we would schedule an colonoscopy 6-8 weeks later to look for possible complications and malignancies

This is done later as well as it is hard to see during an acute setting (especially with blood) whether something is a malignancy or an abscess etc… => very hard to diagnose malignancies acutely

23
Q

What antibiotics would you prescribe to a patient with Acute diverticulitis?

A

IV/PO Co-amox/Cefuroxime + Metronidazole if complicated/simple respectively

24
Q

What is your management plan for a patient presenting to the hospital for a colonoscopy with an incidental finding of diverticula?

A

I will advise them to go for a fibre-rich diet, weight loss, stop smoking, increased exercise without heavy lifting
Change ACEi (causing chronic cough)
I will prescribe probiotics and stool softeners

25
Q

What is your full management of simple acute diverticulitis where a 45 year old patient is somewhat well with LIF tenderness, no rebound tenderness, and no bleeding PA. Include your conservative, medical, and surgical management (including indications but without specifics of complications)

What would you add to the management plan if the patient was also acutely unwell?

A

Conservative: High fiber diet, Probiotics, Stool softener (+reduce RFs)

Medical: PO/IV antibiotics Coamox/pip taz + Gent/Metronidazole

Surgical: US/CT guided Abscess drainage if presence of abscess >3cm
Laparoscopy +/- Washout escalated to Hartmann’s Procedure
Indications:Main -> not resolved on antibiotics, complications of diverticulitis in an uncomplicated presentation => peritonitis (Hinchey Classification III,IV), fistula, undrainable abscess.

Extra points! I will schedule a colonoscopy in 6-8 weeks to look for complications and malignancy as I would not want to risk perforation or bleeding in acute diverticulitis.

In an acutely unwell presentation => acute abdomen => 10 steps

1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) Bowel Rest - NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: EXCEPT IN PANCREATITIS Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)

26
Q

What is Hartmann’s procedure?

A

Proctosigmoidectomy, resecting the diseased segment (sigmoid), leaving the patient with a left-sided stoma

27
Q

In acute diverticulitis how does obstruction occur as a complication?
How would you treat obstruction?

A patient with acute diverticulitis appears with abdominal bloating. What may cause this?

A

Stricture formation from chronic inflammation => luminal narrowing
Stricture tx: Endoscopic dilatation

This is an example of a closed loop obstruction. This happens when the stricture occurs distal to a !competent! caecum => trapping in between caecum and stricture causing distention

28
Q

What is the thinnest part of the bowel?

What is the thinnest part of the colon?
What is the significance of this in the setting of acute diverticulitis?

A

Thinnest part is 15cm proximal to the caecum

Thinnest part of the colon is the caecum => this is where perforation is most likely to occur in the case of a closed loop obstruction due to a stricture distal to a competent caecum in acute diverticulitis.

29
Q

A patient with acute diverticulitis on IV antibiotics are getting recurrent fever spikes. What is the most likely diagnosis? How should it be treated?

A

Acvute diverticulitis complicated by an abscess

This requires IR drainage

30
Q

In acute diverticulitis, Persistant inflammation + microperforations from microorganisms lead to the formation of abscesses.
What are the types (locations) of abscesses seen in acute diverticulitis?
How would a patient present with an abscess?
What are your options for treating the abscess?
How would you treat a Perforated abscess?

A

Pericolic abscess (which may extend into a paracolic abscess)
Paracolic abscess
Distant abscess (pelvic and retroperitoneum)

Presentation: (very vague so no need for all) Spiking fever +unresolving LIF pain +/- systemically unwell + nausea vomiting !despite antibiotics

Tx:
<3cm => conservative management => IV antibiotics of coamox + metronidazole
>3cm => US/CT guided drainage If undrainable => Laparoscopic washout +/- Laparotomy

Perforated abscess = Purulent Peritonitis => Laparoscopic washout +/- Laparotomy (if patient is fit and young, with opinion from senior, antibiotics and close monitoring to avoid surgical insult)

31
Q

In acute diverticulitis, what are the two types of peritonitis?
Which is worse?
How would you treat each type?

A

Purulent Peritonitis due to perforation of an abscess (Hinchey III)
Tx: Laparoscopy and Washout +/- Laparotomy

First class: In a younger, fit patient, IV antibiotics and IR guided drainage may suffice. “but I would confirm with a senior/consultant based on clinical picture”

Faeculent Peritonitis due to perforation of diverticular segment (Hinchey IV)
Tx:
Stable: Primary colonic anastomosis
Unstable: Hartmann’s procedure

32
Q

A patient presents with the symptoms of acute diverticulitis but with pain on the right side. You suspect it might be appendicitis but your consultant shows you the pain is not severe enough and is not maximal on McBurney’s point. What is the explanation to this?

A

Cecal variant (5%) of diverticular disease. rare but exists

33
Q

A patient presenting to the ED complaining of nausea, LIF pain, constipation, pebble-like stool and recurrent UTIs. What is your running diagnosis?

A

Acute Diverticulitis complicated by colovesical fistula

34
Q

Fistula formation is one of the 4 major complications of diverticular disease. What are the 2 most common fistulas formed here?
How would you treat them?

A

Colovesical
Colovaginal

Tx: Resection of affected segment

35
Q

What additional symptoms would be present in a patient diagnosed with acute diverticulitis complicated with colovesical fistula?

What about a colovaginal fistula

A

Recurrent UTIs
Pneumaturia (gas and bubbles in urine)
Debris in urine

Feces/grits PV

Very very important when taking a history

36
Q

What are the only 2 differentials for pneumaturia?

A

Colovesical fistula
Recent catheterization

37
Q

Many patients with acute diverticulitis have longstanding chronic diverticulitis. 30% of patients will haver further attacks after their first presentation and 50% after their second. What is the definitive treatment for these patients suffering from chronic diverticulitis?
What are the indications for this treatment? (4)

A

Tx: Colectomy (could be progressed to colostomy (left sided stoma))
Indications:
1) >2 acute attacks successfully treated
2) 1 attack requiring hospitalization in patient <40
3) 1 complicated attack
4) 1 attack in an immunocompromised patient

38
Q

What classification is used in acute diverticulitis? (List criteria)
List the management for each

A

Hinchey Classification
I - Pericolic or paracolic abscess (IV antibiotics +/- IR CT-guided drainage)
II - Distant abscess (retroperitoneal, pelvic) (IV antibiotics +/- IR CT-guided drainage)
III - Purulent Peritonitis (Laparoscopy + washout - or IV antibiotics and drainage in a fit patient after checking with senior)
IV - Faeculent Peritonitis (hartmann’s/proctosigmoidectomy)

39
Q

A patient is initially wrongfully diagnosed with diverticulitis. They are a vasculopath with intermittent claudication. Family hx shows paternal death due to stroke at 60 and maternal death at 50 due to MI. What is the most likely diagnosis?

A

Ischaemic colitis

40
Q

What is the most common area compromised in ischaemic colitis

A

Watershed area, specifically splenic flexure (left sided and ddx for diverticulitis)

S - Ch. 5 - Colorectal Surgery (4 decks)

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