Diverticular Disease Flashcards
Outline the theory of why diverticula develop?
There is muscular hypertrophy possibly related to having a low fibre diet (increased peristalsis).
In between areas of muscle hypertrophy and where blood vessels enter there are areas of weakness.
Due to high intra-luminal pressure in these areas out-pouches (diverticula) form.
Cholinergic denervation with increasing age may lead to uncoordinated muscle contraction increasing the likelihood of diverticula formation.
Describe the locations in which diverticula are usually found?
Diverticula form in areas of mucosal weakness.
They are often asymptomatic and are found incidentally on CT.
They are often in the sigmoid colon as this is an area of increased intra-luminal pressure.
Describe the difference between diverticulosis and diverticulitis?
Diverticulosis is asymptomatic diverticular disease (95% of cases) and is often found incidentally. It is very common in the elderly 80% of 80 yo.
Diverticulitis is an infected diverticula.
What are the complications of diverticulosis?
Infection: Diverticulitis Abcess formation Perforation Strictures
- Obstruction
- Fistula formation
- Bleeding: chronically causing anaemia or acutely causing blood in stools.
Describe how patients with asymptomatic diverticular disease are managed?
No treatment or follow up is required.
A prophylactic high fibre diet may be of benefit.
Describe the presentation of diverticulitis?
Usually left lower quadrant pain*
Pain may be intermittent or constant.
May be associated with a change in bowel habit (constipation)
Systemic symptoms:
Pyrexia + tachycardia
Anorexia, nausea and vomiting.
Tenderness, guarding
Perforation = Peritonitis + signs of severe infection aka sepsis.
*Can present atypically with RLQ pain (more common in asians)
Describe the management of diverticulitis?
Diagnosis is made with CT scanning. AXR and CXR to assess for complications
Supportive care (fluids, pain relief, NBM) Broad spectrum IV abx: e.g. co-amoxiclav + metronidazole
Describe the management of a perforated diverticula?
Clinical diagnosis of peritonism: CT scan or straight for emergency laparotomy.
Surgery usually involves resection with a primary anastomosis.
Describe the management of haemorrhage in diverticular disease?
Resuscitation if severe.
For most patients, diverticular bleeding is self-limited with bed rest.
Subsequent colonoscopy should be performed to establish the source of the bleeding and to exclude malignancy.
In non self limiting bleeds:
-Intrarterial vasopressin at angiography or angiographic embolism can be used.
What is the management of bowel obstruction caused by a diverticular stricture?
Initial management of NG tube and fluids.
CT and colonoscopy to rule out malignancy.
Resect bowel if you cannot rule out malignancy.
If malignancy ruled can trial endoscopic (colonoscopy) balloon dilation.
Describe the management of abscess formation due to diverticular disease?
Small pericolic abscess: conservative treatment with bowel rest and abx.
If larger, distant or unresolving:
-CT-guided percutaneous drainage of abdominal abscesses is now used in preference to surgery.
Describe the presentation of colovesical and colovaginal fistula?
Colovesical:
- Pneumaturia (frothy urine)
- Faecaluria
- Recurrent UTI
- Passage of urine rectally
Colovaginal:
- Passage of gas, stool or pus from your vagina
- Foul-smelling vaginal discharge
- Recurrent vaginal or urinary tract infections
Describe the management of fistulae caused by diverticular disease?
Surgery is needed.
Colovesical (bladder to bowel): Single stage resection and fistula repair.
Colovaginal: Surgical resection of the affected colon and repair of the vagina.
What are the indications for surgery in diverticular disease?
Peritonitis due to perforation Uncontrolled sepsis Fistula Obstruction Inability to exclude malignancy
What is Meckel’s diverticulum?
It is a congenital abnormality where the is a remenant of the vitelline duct (a duct connecting the yolk sac and foetal midgut) forming a diverticulum.
Rule of 2’s
2 feet away from the ileocaecal junction 2% of the population Most commonly presents at 2 2 inches in length 2:1 male to female ratio 2 types of cells (gastric acid secreting or pancreatic tissue)
