Diverticular Disease

Question 1

Define Diverticular Disease

Answer 1

Diverticulosis associated with complications, e.g. haemorrhage, infection, fistulae.

Question 2

Define Diverticulitis.

Answer 2

Acute inflammation and infection of colonic diverticulae.

Question 3

Describe the aetiology of Diverticular disease.

Answer 3

A low-fibre diet leads to loss of stool bulk.

Consequently, high colonic intraluminal pressures must be generated to propel the stool, leading to herniation of the mucosa and submucosa through the muscularis.

Question 4

Give a brief overview of the pathogenesis of Diverticular disease.

Answer 4

Diverticulae are most common in the sigmoid and descending colon but can be right sided.

Absent from the rectum.

Diverticulae consist of herniated mucosa and submucosa through the muscularis, particularly at sites of nutrient artery penetration.

Proposed diverticular obstruction by inspissated faeces can lead to bacterial overgrowth, toxin production and mucosal injury and diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation or stricture formation.

Question 5

Describe the epidemiology of Diverticular disease?

Answer 5

Common,

60% of people living in industrialized countries will develop colonic diverticula,

rare

Question 6

What would a patient suffering with Diverticular disease describe in their history?
•consider complications.

Answer 6

Often asymptomatic (80–90%).

Complications include: pr bleeding, diverticulitis: typically, left iliac fossa or lower abdominal pain, fever.

Diverticular fistulation into bladder: pneumaturia, faecaluria and recurrent UTI.

Question 7

What would be found on examination of a patient with Diverticular disease?

Answer 7

Examination is usually normal.

Diverticulitis: Tender abdomen; signs of local or generalized peritonitis if perforation has occurred.

Question 8

What investigations would you perform on a patient with suspected Diverticular disease?

Answer 8

Bloods:
FBC, ⬆️ WCC and ⬆️ CRP in diverticulitis,
check clotting and cross-match if bleeding.

Barium enema ( +/- air contrast): 
Demonstrates the presence of diverticulae with a saw-tooth appearance of lumen, reflecting pseudohypertrophy of circular muscle 
(should not be performed in acute setting as there is a danger of perforation).

Flexible sigmoidoscopy and colonoscopy: 
Diverticulae can be seen 
other pathology (e.g. polyps or tumour) can be excluded.

In an acute setting:
CT scan for evidence of diverticular disease and complications.

Question 9

How would you manage a patient with Diverticular disease?

Answer 9

Asymptomatic:
•Soluble high-fibre diet (20–30 g/day).
•osmotic laxatives soften stool whilst bulk-forming laxatives increase faecal mass, stimulating peristalsis.
•antispasmodic drugs relax intestinal smooth muscle and reduce painful spasm.
•Probiotics and anti-inflammatories (mesalazine) are under investigation for preventing recurrent flares of diverticulitis.

GI bleed:
•PR bleeding is often managed conservatively with IV rehydration, antibiotics, blood transfusion if necessary.
•Angiography and embolization or surgery if severe.

Diverticulitis:
•Treated by IV antibiotics and IV fluid rehydration and bowel rest. •Localized collections or abscesses may be treated by radiologically sited drains.

Surgery:
•May be necessary with recurrent attacks or when complications develop, e.g. perforation and peritonitis.
•Surgical treatment can be by open or laparoscopic approaches.

• Open:—Hartmann’s procedure (resection and stoma) or one-stage resection and anastomosis (risk of leak)+/-defunctioning stoma.
• laparoscopic drainage, peritoneal lavage and drain placement can be effective.

Question 10

What complications are associated with Diverticular disease?

Answer 10

Diverticulitis, 
pericolic abscess, 
perforation, 
faecal peritonitis, 
colonic obstruction, 
fistula formation (bladder, small intestine, vagina), 
haemorrhage.

Question 11

What is the prognosis for patients with Diverticular disease?

Answer 11

Ten to 25% of patients will have one or more episodes of diverticulitis. Of these, 30% will have a second episode.

Question 12

Describe a Hartmann’s procedure.

Answer 12

It is an emergency two stage procedure done when the bowl is unprepared/peritonitis is present and risk of anastomoses breakdown and infection is too high for primary anastamosis.

Initial resection is followed later by anastamosis once signs of infection have removed for at least three months.
Temporary loop ileostomy or colostomy may be used to protect colorectal anastamosis.

Only 70% proceed with second stage because of co morbidity.

Signs of infection:
Temperature
ECC
ESR/CRP

Question 13

Define diverticulosis.

Answer 13

The presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel.