DIVERTICULAR DISEASE

Question 1

Define diverticular disease

Answer 1

Diverticulosis associated with complications e.g. haemorrhage, infection, fistulae

Question 2

Define diverticulosis and diverticulitis

Answer 2

o Diverticulosis: the presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
o Diverticulitis: acute inflammation and infection of colonic diverticulae

Question 3

Hinchey Classification of Acute Diverticulitis:

Answer 3

• Ia: phlegmon
• Ib and II: localised abscesses
• III: perforation and purulent peritonitis
• IV: faecal peritonitis

Question 4

Explain the aetiology and pathogenesis of diverticular disease

Answer 4

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
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

PATHOGENESIS
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

Question 5

Where are diverticulae most commonly found in the GIT

Answer 5

Sigmoid
Descending colon
(never found in the rectum)

Question 6

Summarise the epidemiology of diverticular disease

Answer 6

• 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

Question 7

Recognise the presenting symptoms of diverticular disease

Answer 7

Often ASYMPTOMATIC (80M90%)

Complications can lead to symptoms such as:
o PR bleeding
o Diverticulitis (causing LIF and lower abdominal pain and fever)
o Diverticular fistulation (causing pneumaturia, faecaluria and recurrent UTI)

Question 8

Recognise the signs of diverticular disease on physical examination

Answer 8

Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated

Question 9

Identify appropriate investigations for diverticular disease

Answer 9

BLOODS
o FBC: increased WCC, increased CRP
o Check clotting and cross-match if bleeding

BARIUM ENEMA (with or without air contrast):
o Shows presence of diverticulae (sawJtooth 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

Question 10

What investigations are appropriate in the ACUTE setting?

Answer 10

CT scan for evidence of diverticular disease and complications may be performed

Question 11

Generate a management plan for diverticular disease

Answer 11

ASYMPTOMATIC
o Soluble high-fibre diet (20M30 g/day)
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  IV antibiotics  
o  IV fluid rehydration  
o  Bowel rest  
o  Abscesses ma be drained by radiologically sited drains  

SURGERY
May be necessary in patients with recurrent attacks or complications (e.g. perforation and peritonitis)
Open surgery:
• Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
• One-stage resection and anastomosis (risk of leak) - with or without defunctioning stoma
• Laparoscopic drainage, peritoneal lavage and drain placement can be effective

Question 12

Identify the possible complications of diverticular disease

Answer 12

• Diverticulitis
• Pericolic abscess
• Perforation
• Faecal peritonitis
• Colonic obstruction
• Fistula formation (bladder, small intestine, vagina)
• Haemorrhage

Question 13

Summarise the prognosis for patients with diverticular disease

Answer 13

• 10-25% have one or more episodes of diverticulitis