Diverticular disease

Question 1

Define:

1. Diverticulosis
2. Diverticulitis
3. Diverticular disease

Answer 1

1. Diverticulosis (usually no symptoms although may be bleeding): the presence of diverticula (pouches that form in a hallow structure in the body, colonic diverticula = pouch formation in large intestine)
2. Diveticulitis: the inflammation of diverticula
3. Diverticular disease: symptomatic diverticula

Question 3

Outline the theories on the aetiology of diverticulosis of the colon

Answer 3

• There is thickening of the muscle layer and because of high intraluminal pressures, pouches of mucosa extrude through the muscular wall through weakened areas near blood vessels to form diverticula
• Cholinergic denervation with increasing age will lead to hypersensitivity and increased uncoordinated muscular contraction, which may lead to pouch formation
• It may be related to low-fibre diet, which induces a muscular hypertrophy, and an increase in intraluminal pressure
• Diverticulitis occurs when faeces obstruct the neck of the diverticulum causing stagnation and allowing bacteria to multiply
• This can then lead to perforation, abscess formation, fistulae or generalized peritonitis.

Question 4

Describe the morphology and pathological consequences of diverticulosis of the colon

Answer 4

• 95% of diverticulae are asymptomatic
• Diverticulosis takes the form of outpouchings of mucosa, which are weak. They have a peritoneal surrounding.
• Impaction of faecolith (faecal matter) within the diverticulum, similar to in appendicitis, will cause irritation, and may eventually lead to rupture
• Inflammation and ulceration may result in abscess formation, fistulae and haemorrhage
• Repeated attacks of diverticulitis trigger fibro-muscular thickening, and stenosis
• All inflammatory pathologies may stimulate carcinoma.

Question 5

Where does diverticula most commonly occur? Why?

Answer 5

The sigmoid colon with 95% of complications arising at this site. This is because it is the narrowest point and therefore has highest pressure

Question 6

Describe the clinical features of diverticulosis of the colon

Answer 6

Diverticulosis

• asymptomatic in 95% of cases and found incidentally on barium enema.
• If symptomatic they exactly mimic carcinoma colon (diverticular disease).

Question 7

Outline the complications of diverticulosis

Answer 7

Diverticula may complicate to perforation (in association with acute diverticulosis), fistula formation (into bladder or vagina), intestinal obstruction, and bleeding with mucosal inflammation.

Question 8

What are the clinical features of diverticular disease?

Answer 8

• Left sided colic, relieved by defecation
• Altered bowel habit (including blood and mucus passage)
• Nausea
• Flatulence
• Severe pain and constipation if severe (causing luminal narrowing)

Question 9

Describe the signs and symptoms of diverticulitis

Answer 9

Infection occurs due to stagnation of the contents of the diverticula

Symptoms:

• Severe left sided colic
• Constipation (or overflow diarrhoea)
• Symptoms mimicking appendicitis but on the left

Signs:

• Fever & tachycardia
• Tenderness, guarding & rigidity on the left hand side
• Can be palpable mass in the LIF
• Raised WCC and inflammatory markers

Question 10

Primary differential diagnosis for left iliac fossa pain?

Answer 10

diverticulitis as not many other causes of LIF pain