Diverticular Disease Flashcards
What is a diverticulum?
An abnormal outpouching of a hollow viscus into the surrounding tissue
What is a true and what is a false diverticulum?
A true diverticulum involves all the layers of the wall of the viscus
A false diverticulum doesn’t involve all the layers e.g. an oesophageal false diverticulum only includes the mucosa and submucosa
What are the different examples of diverticulae?
Bowel: most commonly in the sigmoid colon (45% of cases)
Meckel’s: caused by a remnant of the vitelline/omphalomesenteric duct, rule of 2s (2% of population, 2 inches in length, located 2 feet from the ileocaecal valve, usually presents before the age of 2)
Bladder: associated with bladder outflow obstruction
Pharyngeal pouch: herniates through the inferior constrictor muscles
Where in the bowel wall do diverticulae occur?
They occur at the weakest points of the bowel wall - at the junctions of the triangular muscle sheets which is where the nutrient arteries penetrate
What is diverticulosis?
The presence of asymptomatic diverticulae
What is diverticular disease?
Symptoms arising from the diverticulae
What is diverticulitis?
Inflammation of the diverticulae
Who is at risk of diverticular disease?
Age - 50% over 50 and 70% over 80 have diverticulosis
Men > Women
Developed countries - due to low fibre diet
How does diverticular disease present?
Incidental CT finding (diverticulosis)
Acutely - diverticulitis, diverticular bleed:
LIF pain
Tenderness
Local peritonism
Systemic upset
Haemorrhage
Non-Acutely:
Change in bowel habit - pellet-like stools
Bloating
How to classify diverticulitis?
Uncomplicated or complicated
Complications include:
- Abscess - generally managed with antibiotics, IR drainage may be required
- Perforation - requires laparotomy and resection
- Fistula - colovesical, colovaginal
- Stricture - resulting in large bowel obstruction, requires surgery
How to investigate diverticulitis?
Bedside
Bloods
Imaging
- CT AP: for diagnosis and to assess for complications
- Colonoscopy after 6-8 weeks to confirm diagnosis and assess for underlying issues
How to stage acute diverticulitis?
Hinchey Classification:
- 1a = presence of phlegmon (inflammatory pericolic mass)
- 1b = presence of pericolic or mesenteric abscess
- 2 = presence of walled off pelvic abscess
- 3 = generalised purulent peritonitis
- 4 = generalised faecal peritonitis
How to manage diverticular disease?
Acute (Diverticulitis):
Analgesia
Bowel rest/low residue diet
Antibiotics
IV fluids
?Surgery for complications
Non-Acute:
Analgesia
Fluids
Increase dietary fibre
Diverticular bleeds are generally conservatively managed with/without blood products, but severe bleeding will require a CT angiogram to confirm the site of bleeding and surgery
If there is deterioration/failed conservative management, consider repeating the CT scan and surgery
What is the operation for diverticular perforation?
Hartmann’s procedure = sigmoid colectomy with formation of an end colostomy
A delayed reversal can be performed later down the line
