Diverticular Disease Flashcards
What layers are involved in Diverticular disease?
While you’re at it, state all the layers
Mucosal and submucosal layers => pseudodiverticula
Mucosa, submucosa, circular muscles, Auerbach plexus, longitudinal muscles, serosa including meissner’s plexus
Define Diverticula
!Acquired sac-like herniation of the mucosa and submucosa through the colonic wall
Define Diverticulosis
Presence of diverticula without inflammation!
Define Diverticulitis
Give 3 specific symptoms
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)
Where does the herniation typically occur?
What are the most common locations for Diverticulosis? State them in descending order of prevalence.
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
What is meant by true and false diverticula?
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
Give an example of a true diverticula
Meckel’s diverticulum (congenital)
Give 7RF for Diverticular disease. total = 9
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)
What is the pathogenesis of Diverticular disease from low fibre diet?
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)
What is the most common presentation of a patient with diverticulosis?
Diverticulosis = presence of diverticula without inflammation
The vast majority of patients are found incidentally during colonoscopy or barium enema => asymptomatic
50% of those over 50 have diverticula. 25% of which are actually symptomatic => diverticulitis. What is the typical clinical presentation of simple acute diverticulitis?
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
State the complications of Acute Diverticulitis or Diverticular disease as a whole
GI haemorrhage
Obstruction/stricture formation
Abscess formation
Perforation/Peritonitis
Diverticular Fistula
A patient presents with simple acute diverticulitis with painless spontaneous bleeding. What is the significance of quantifying the volume?
Small volume = normal erosion of mural vessels by diverticulitis
Large volume = Rupture of a peri diverticular vessel
What is Rebound Tenderness a sign of?
Inflammation or irritation of the peritoneum => Peritonitis
What result do you expect to see on an FBC in Diverticulitis
Anaemia (fe-deficiency or normocytic due to haemorrhage)
WCC - raised, mostly PMN (neutrophilia)
What do you expect to see on a U&E in acute diverticulitis
Hypokalaemia
What imaging will you order for a patient with acute diverticulitis?
Erect CXR
PFA (rarely done)
CT angiography
CT abdomen and Pelvis with IV contrast
Why would you send a request for CT angiography in the context of acute diverticulitis?
CT angiography to detect active bleeding, vascular compromise, perforations
Therapeutic: IR embolization in severe haemorrhage
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?
To screen for complications including fistula
Oral contrast best for fistulas (rarely used)
What are the investigations you will conduct in the setting of acute diverticulitis? (rationale where applicable)
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
In the case of acute diverticulitis, what do you see in each phase of the CT?
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)
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
What antibiotics would you prescribe to a patient with Acute diverticulitis?
IV/PO Co-amox/Cefuroxime + Metronidazole if complicated/simple respectively
What is your management plan for a patient presenting to the hospital for a colonoscopy with an incidental finding of diverticula?
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
