Diverticular Disease

Question 1

What section of the colon is diverticular disease most commonly found?

Answer 1

The sigmoid colon

Note the right sided colon is more commonly affected in those of Asian descent.

Question 2

What are some risk factors for diverticular disease?

Answer 2

Age - rare before 40, 80% of over 85yrs have (most commonly if constipated)
Smoking - diverticulitis and bleed
Diet - low in fibre and high in red meat
Obesity
Family history
Medication - NSAIDs, steroid inc risk of perforation

Question 3

What is diverticula?

Answer 3

Sac like protrusion of the intestinal mucosa through the muscular wall

Question 4

What is diverticulosis?

Answer 4

Presence of asymptomatic diverticula

Question 5

What is diverticular disease?

Answer 5

Symptomatic diverticula e.g abdominal pain, in the absence of inflammation (also used an umbrella term)

Question 5

What is diverticulitis?

Answer 5

Symptomatic acute inflammation and infection of diverticula

Question 6

What is diverticulosis?

Answer 6

Presence of asymptomatic diverticula

Question 7

How is diverticulosis often diagnosed?

Answer 7

Incidentally on images - CT abdomen or colonscopy.

Question 8

What is shown on this colonscopy?

Answer 8

Diverticular disease

Question 9

What are the different symptoms of diverticular disease?

Answer 9

Intermittent lower abdominal pain - colicky pain
Pain relieved by defecation
Altered bowel habit - constipation/diarrhoea
Occasionally blood/mucus in stool.

Question 10

What are the signs and symptoms of diverticulitis?

Answer 10

Symptoms - more severe abdo pain, PR bleeding, fever
Signs - abdominal tenderness, possibly septic,
If rupture - peritonitic.
If perforation - may be localised or generalised guarding, these patients are often very unwell and deteriorate quickly.

Question 11

What investigations would you order for a patient with suspected diverticulitis?

Answer 11

Rule out similar: IBS, coeliac disease, bowel cancer
Confirm presence of diverticula: colonoscopy, CT abdomen
For diverticulitis (unwell patient): Acute abdomen’ investigations.

Question 12

What are some common complications of diverticulitis?

Answer 12

Abscess or fistula formation
Colonic stricture - bowel obstruction
Diverticular bleed
Perforation

Question 13

What is a fistula complication of diverticulitis?

Answer 13

Repeated or persistent inflammation between two intra-abdominal organs may lead to the formation of a fistula - an abnormal connection between two epithelial surfaces.
Commonly, they are colovaginal or colovesical.

Question 14

What is a colonic stricture as a complication of diverticulitis?

Answer 14

Repeated epsidoes of diverticulitis and inflammation leads to scar tissue and strictire formation.
Results in change in bowel habits and large bowel obstruction

Question 15

What is diverticular bleed as a complications of diverticulitis?

Answer 15

Diverticula lead to weakening of adjacent vessel walls and resulting bleeding

Question 16

How is perforation a complication of diverticulitis?

Answer 16

Repeated episodes of diverticulitis weaken the bowel wall.

Question 17

What is the management of diverticular disease?

Answer 17

Analgesia (avoid opiods as can cause constipation)
Address lifestyle factors

Question 18

What is the management of diverticulitis?

Answer 18

Analgesia (avoid opioids as cause constipation)
Address lifestyle factors
Antibiotics
If repeated flare ups should refer to general surgery
May require surgery if evidence of complications aka bowel resection for strictures/obstruction, percutaneous drainage for abscess.

Question 19

What is the relevant pathophysiology of diverticular disease?

Answer 19

The musclaris layer of the gut wall, has areas of weakness particularly in the circular layer where it is penetrated by blood vessel
Increase pressure inside the lumen can cause gaps to form in these area,
Mucosa can herniate through the muscle later to form pouches
These are false diverticula as the muscle layer does not herniate (only the mucosa does).
Areas not covered by Teniae coli are the most vulnerable
Faecal lodegement - can cause ischemic necrosis causing inflammation, alternatively gut microflora may cause inflammation leading to diverticulitis.