Diverticular disease Flashcards
What are the cause, clinical features and mx of jejunal diverticula?
Uncommon, probably congenital. Multiple herniated areas through mesenteric aspect of jejunum. Fx:
-perforation of one diverticulum
-macrocytic anaemia (?infection with SB bacterial overgrowth)
-enterolith formation with SBO
Mx: surgical for emergencies, ABx for bacterial overgrowth.
What is the law of 2s of Meckel’s diverticulum?
- 2% of population
- 2ft (60cm) from ileocaecal valve
- 2 inches (5cm) in length
- 2x as common in males.
- 2 types of ectopic tissue (gastric and pancreatic)
- 2 years of age common presentation
How may Meckel’s diverticulum present?
- persistent vitello-umbilical fistula
- acute diverticulitis mimicking appendicitis
- perforation and peritonitis due to retained foreign body (e.g. fish bone)
- intestinal obstruction (diverticulum or attached band is attached to the umbilicus and causes a SB volvulus or internal herniation)
- intestinal obstruction caused by ileo-ileal intussception
- pain or bleeding 2’ to PUD of ectopic parietal cells
Describe PUD of Meckel’s diverticulum.
Peptic ulcer occurs on mesenteric border of the adjacent ileum. Presents with pain and lower SB bleeding.
Generally in children or young adults.
Confirm with angiography or radionuclide scanning.
Mx Meckel’s diverticulum?
Asymptomatic incidental discovery in child removed.
Adult >30y - innocuous so leave.
Symptomatic dealt with according to complications.
What is Meckel’s diverticulum?
Congenital diverticulum of ileum: remnant of the Vitelline (omphalomesenteric) duct.
Are diverticula more frequently congenital or acquired? Distinction??
Congenital: rare. Contains all layers of normal colon.
Acquired: series covered outpouchings of mucosa through gaps in muscular propria (which transmit terminal blood vessles).
Where are diverticula most frequently found?
Left colon esp sigmoid (but may involve entire colon).
What is the epidemiology of diverticula disease?
Rare
What is the aetiology of diverticula disease?
Low fibre diet -> increased intraluminal pressure -> pulsing herniation of mucosa alongside blood vessels.
What are the pathological outcomes of diverticula disease?
i) Persistent inflammation in segment of bowel wall
ii) local inflammation of affected diverticulum –> perforation
Where may diverticula perforate into?
i) local into pericolic tissues
ii) into peritoneal cavity with generalised peritonitis
iii) into adjacent organ (e.g. bladder) with fistula formation
How is diverticular disease generally investigated?
Barium enema or colonoscopy.
Diverticular disease may conceal coexistence CRCa so colonoscopy best.
How should uncomplicated diverticulitis be managed?
Consider increasing fibre (e.g. supplement). No evidence it presents development but may relieve mild symptoms.
What are the inflammatory complications of diverticular disease and their management?
Inflammation of bowel wall segment may cause severe pain, pyrexia and tenderness at site.
May progress to local perforation with collection of inflammatory tissue and pus around sigmoid colon (pericolic abscess); detected as a mass.
Ix: U/S or CT
Mx: early = ABx; abscess = surgery.
How is colonic perforation due to diverticular disease classified?
Hinchey Classification for colonic perforation due to diverticular disease:
Hinchey I: localised abscess (paracolonic)
Hinchey II: pelvic abscess
Hinchey III: purulent peritonitis
Hinchey IV: faeculent peritonitis
How does diverticular disease lead to peritonitis?
Process similar to gangrenous appendicitis. Facecloth impacts in mouth of diverticulum -> obstructs blood supply, may rupture.
What are the features of peritonitis secondary to rupture of a diverticulum?
- generalised abdo pain, often with tip of the shoulder pain due to pneumoperitoneum
- signs of severe sepsis: fever and circulatory collapse
- abdo tenderness and rigidity
How should peritonitis from diverticulum be managed?
Surgical emergency.
May require colonic resection with temporary stoma formation with later surgical correction to continuity.
Describe the clinical features of diverticulitis precipitating distillation.
Depends on structures involved:
- pericolic: may only be found on barium enema
- bladder: pneumaturia and frequent infection
- vagina: pv passage of gas and faeces
Can diverticular disease precipitate haemorrhage?
YES. Large-volume rectal haemorrhage thought to result from erosion of a vessel in neck of diverticulum.
Diverticular disease commonest cause of large-volume rectal bleeding, esp 50y+.
Can rapidly exsanguinate.
How can diverticular haemorrhage be diagnosed?
May be difficult to localise in pts with extensive disease. Selective angiography of large bowel arteries usually required.
Rx: radiological (embolisation) or surgical (limited resection/subtotal colectomy + anastomosis).
