Diverticular disease

Question 1

What are the cause, clinical features and mx of jejunal diverticula?

Answer 1

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.

Question 2

What is the law of 2s of Meckel’s diverticulum?

Answer 2

• 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

Question 3

How may Meckel’s diverticulum present?

Answer 3

• 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

Question 4

Describe PUD of Meckel’s diverticulum.

Answer 4

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.

Question 5

Mx Meckel’s diverticulum?

Answer 5

Asymptomatic incidental discovery in child removed.
Adult >30y - innocuous so leave.
Symptomatic dealt with according to complications.

Question 6

What is Meckel’s diverticulum?

Answer 6

Congenital diverticulum of ileum: remnant of the Vitelline (omphalomesenteric) duct.

Question 7

Are diverticula more frequently congenital or acquired? Distinction??

Answer 7

Congenital: rare. Contains all layers of normal colon.
Acquired: series covered outpouchings of mucosa through gaps in muscular propria (which transmit terminal blood vessles).

Question 8

Where are diverticula most frequently found?

Answer 8

Left colon esp sigmoid (but may involve entire colon).

Question 9

What is the epidemiology of diverticula disease?

Answer 9

Rare

Question 10

What is the aetiology of diverticula disease?

Answer 10

Low fibre diet -> increased intraluminal pressure -> pulsing herniation of mucosa alongside blood vessels.

Question 11

What are the pathological outcomes of diverticula disease?

Answer 11

i) Persistent inflammation in segment of bowel wall

ii) local inflammation of affected diverticulum –> perforation

Question 12

Where may diverticula perforate into?

Answer 12

i) local into pericolic tissues
ii) into peritoneal cavity with generalised peritonitis
iii) into adjacent organ (e.g. bladder) with fistula formation

Question 13

How is diverticular disease generally investigated?

Answer 13

Barium enema or colonoscopy.

Diverticular disease may conceal coexistence CRCa so colonoscopy best.

Question 14

How should uncomplicated diverticulitis be managed?

Answer 14

Consider increasing fibre (e.g. supplement). No evidence it presents development but may relieve mild symptoms.

Question 15

What are the inflammatory complications of diverticular disease and their management?

Answer 15

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.

Question 16

How is colonic perforation due to diverticular disease classified?

Answer 16

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

Question 17

How does diverticular disease lead to peritonitis?

Answer 17

Process similar to gangrenous appendicitis. Facecloth impacts in mouth of diverticulum -> obstructs blood supply, may rupture.

Question 18

What are the features of peritonitis secondary to rupture of a diverticulum?

Answer 18

• 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

Question 19

How should peritonitis from diverticulum be managed?

Answer 19

Surgical emergency.

May require colonic resection with temporary stoma formation with later surgical correction to continuity.

Question 20

Describe the clinical features of diverticulitis precipitating distillation.

Answer 20

Depends on structures involved:

• pericolic: may only be found on barium enema
• bladder: pneumaturia and frequent infection
• vagina: pv passage of gas and faeces

Question 21

Can diverticular disease precipitate haemorrhage?

Answer 21

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.

Question 22

How can diverticular haemorrhage be diagnosed?

Answer 22

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).