Diverticular Disease

Question 1

What is a GI diverticulum?

Answer 1

Outpockets of colonic muscosa/submucosa usually at sites of perforation by arteries. NOT INFLAMED

Question 2

What is diverticular disease?

Answer 2

Divertuclum have become symptomatic

Question 3

What is diverticulitis?

Answer 3

Inflammation of diverticulum

Question 4

What are the two main types of diveritculum?

Answer 4

Aquired

Congenital

Question 5

What causes diverticulum?

Answer 5

UNKNOWN, SEVERAL THEORIES

• fibre deficiency
• change in strength of colonic wall w/ age/CT deficiencies

Question 6

Describe the fibre deficiency theory

Answer 6

Lack of dietary fibre –> high intraluminal pressure –> mucosa herniates adjacent to perforating arteries

Question 7

Describe the colonic wall theory

Answer 7

Change in strength of colonic wall due to
-age
-CT disorders
-collagen disorder
Weakened, increased risk of diverticulitis

Question 8

What are the risk factors for diverticular disease?

Answer 8

>50
Low dietary fibre
Obesity
Smoking
NSAIDs/Paracetamol
Marfans, Ehler's-Danlos, PKD

Question 9

Where do most diverticulum occur?

Answer 9

Sigmoid colon

-95% of complications here

Question 10

In what less common places can diverticulum occur?

Answer 10

Right colon

Massive single diverticulum anywhere

Question 11

What are the complications of diverticulosis?

Answer 11

Perforation
Abscess formation
Bleeding
Fistula formation

Question 12

What are the symptoms/signs of diverticular disease?

Answer 12

Can be asymptomatic
Left sided colic (relieved by defecation
Altered bowel habit (blood/mucus)
Nausea
Flatulence
Severe pain/constipation (if luminal narrowing)

Question 13

What investigations are appropriate in suspected diverticular disease?

Answer 13

PR (pelvic abscess? colorectal cancer?)
Sigmoidoscopy/Colonoscopy
Barium enema
CT

Question 14

What is the 1st line medical management for diverticular disease?

Answer 14

Mebeverine

Question 15

What is diverticulosis?

Answer 15

The presence of diverticula

Question 16

What causes diverticulitis?

Answer 16

Infection due to stagnation of contents of diverticula

Question 17

What are the sx of diverticulitis?

Answer 17

Severe L. sided colic
Constipation (or overflow diarrhoea)
Sx mimicking appendicitis BUT on the left

Question 18

What are the signs of diverticulitis?

Answer 18

Fever
Tachycardia
Tenderness, guarding, rigidity (on LHS)
Palpable mass in LIF
Raised WCC/inflam markers

Question 19

What are the management options for mild attacks of diverticulitis?

Answer 19

UNCOMPLICATED - LOW GRADE FEVER

• bowel rest (fluids only) at home
• oral co-amoxiclav +/- metronidazole

Question 20

What are the management options for severe attacks of diverticulitis?

Answer 20

COMPLICATED - HIGH GRADE FEVER

• admit if pain cannot be controlled/oral fluids not tolerated
• analgesia, IV fluids, NBM
• IV cefuroxime & metronidazole
• erect CXR, AXR, contrast CT
• DO NOT SCOPE

Question 21

What are the potential complications of diverticulosis?

Answer 21

Perforation
Abscess formation
Bleeding
Fistula formation
Intestinal obstruction
Strictures

Question 22

What are the key features of perforation, as a complication of diverticulosis?

Answer 22

Usually in acute diverticulitis
Can lead to abscess formation/peritonitis/fistula
Presents w/ ileus & peritonitis +/- shock
Mortality 40%
Manage w/ laparotomy +/- Hartmann’s

Question 23

What are the key features of abscess formation, as a complication of diverticulosis?

Answer 23

Presents w/ swinging fever, leucocytosis & localising signs
Drain under CT guidance

Question 24

What are the key features of bleeding, as a complication of diverticulosis?

Answer 24

Sudden painless OR chronic occult
Large volumes can be lost
Often stop w/ bed rest
If do not stop treat w/ angiography + embolisation
-adrenaline injections & diathermy may negate need for surgery

Question 25

What are the key features of fistula formation, as a complication of diverticulosis?

Answer 25

Colovesical - UTI & pneumaturia

Colovaginal - foul discharge

Question 26

What are the key features of intestinal obstruction, as a complication of diverticulosis?

Answer 26

Most commonly in sigmoid, after repeated bouts
Scarring, formation of diverticular mass
May mimic colonic carcinoma

Question 27

What are the key features of strictures, as a complication of diverticulosis?

Answer 27

Post-infective strictures in colon

Hard to distinguish from malignant strictures on barium studies

Question 28

How should asymptomatic diverticulae be managed?

Answer 28

Dietary advice only

• avoid processed food
• increase dietary fibre (>20g/day)

Question 29

How should uncomplicated but symptomatic diverticular disease be managed?

Answer 29

Mebeverine

If v. severe/recurrent consider surgery

Question 30

What are the indications for surgical management of diverticular disease?

Answer 30

V. severe/recurrent (rarely resorted to)
Small, confined, pericolonic abscesses (rarely)
Generalised peritonitis (all)
Massive haemorrhage/perforation (emergency colonic resection)