Diverticular disease Flashcards
Define
• It is important to distinguish between the different terms used when discussing patients with diverticular disease
o Diverticulosis: the presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
o Diverticular Disease: diverticulosis associated with complications e.g. haemorrhage, infection, fistulae
o Diverticulitis: acute inflammation and infection of colonic diverticulae
What’s the aetiology?
o A low-fibre diet leads to loss of stool bulk
o This leads to the generation of high colonic intraluminal pressures to propel the stool out
o This, in turn, leads to the herniation of the mucosa and submucosa through the muscularis
What’s the pathogenesis?
o Diveticulae are most commonly found in the sigmoid and descending colon
o However, they can also be right-sided
o Diverticulae are NOT found in the rectum
o Diverticular are found particularly at sites of nutrient artery penetration
o Diverticular obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury
o Which can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation or stricture formation
What are the risk factors?
Age >50
Low fibre diet
Epidemiology
- Diverticular disease is VERY COMMON
- 60% of people living in industrialised countries will develop colonic diverticulae
- Rare < 40 yrs
- Right-sided diverticulae are more common in Asia
What are the presenting symptoms?
• Often ASYMPTOMATIC (80-90%)
• Bloating, constipation
• Complications can lead to symptoms such as:
o PR bleeding (usually abrupt)
o Diverticulitis (causing LIF and lower abdominal pain and fever)
o Diverticular fistulation (causing pneumaturia, faecaluria and recurrent UTI)
What are the signs?
• Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated
What are the appropriate investigations?
• Bloods:
o FBC: increased WCC, increased CRP
o Check clotting and cross-match if bleeding
o Polymorphonuclear leucocytosis
• Abdominal x-ray
• CT scan – scan of choice to confirm suspicion
• Barium Enema (with or without air contrast):
o Shows presence of diverticulae (saw-tooth appearance of lumen)
o This reflects pseudohypertrohy of circular muscle
o IMPORTANT: barium enema should NOT be performed in the acute setting because there is a high risk of perforation
• Flexible Sigmoidoscopy and Colonoscopy:
o Diverticulae can be visualised and other pathology (e.g. polyps and tumours) can be excluded
• In ACUTE setting: CT scan for evidence of diverticular disease and complications may be performed
How do you manage?
• Asymptomatic:
o Soluble high-fibre diet (20-30 g/day)
o No treatment
o Some drugs are under investigation for their use in preventing recurrent flares of diverticulitis (such as probiotics and anti-inflammatories)
• GI Bleed:
o PR bleeding usually managed conservatively with IV rehydration, antibiotics and blood transfusion if necessary
o Angiography and embolisation or surgery if severe
• Diverticulitis:
o Oral or IV antibiotics
o IV fluid rehydration
o Analgesia
o Bowel rest
o Abscesses may be drained by radiologically sited drains
• Surgery:
o May be necessary in patients with recurrent attacks or complications (e.g. perforation and peritonitis)
o Open surgery:
• Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
• One-stage resection and anastomosis (risk of leak) - with or without defunctioning stoma
o Laparoscopic drainage, peritoneal lavage and drain placement can be effective
What are the possible complications?
- Diverticulitis
- Abscess
- Perforation
- Strictures, obstruction
- Faecal peritonitis
- Colonic obstruction
- Fistula formation (bladder, small intestine, vagina)
- Haemorrhage
What’s the prognosis?
- 10-25% have one or more episodes of diverticulitis
* 1/3 of patients have recurrence
