Diverticular disease Flashcards
What is diverticular disease?
Diverticular disease = presence of diverticulae outpouchings/herniae of the colonic mucosa and submucosa through the muscular wall of the bowel – in a clinical state with complications (e.g. haemorrhage, infection, fistulae)
Diverticulosis = without complications Diverticulitis = acute inflammation and infection
Hinchey classification of acute diverticulitis
1a = phlegmon
1b/2 = localised abscesses
3 = perforation with purulent peritonitis
4 = faecal peritonitis
What is the aetiology of diverticular disease?
Both genetic and environmental factors
A low-fibre diet leads to loss of stool bulk, causing high colonic intraluminal pressures needed to propel the stool
Alterations in colonic wall structure and abnormal colonic motility may also contribute
Saint’s triad (hiatus hernia, diverticulosis, gall stones) may be due to connective tissue abnormalities
What are the risk factors for diverticular disease?
Low dietary fibre Age >50 Incidence = increased in older people, extremely rare in children Due to decreasing mechanical strength of colonic walls, due to changes in collagen structure Western diet Increased risk of complications Obesity NSAID use
What is the epidemiology for diverticular disease?
Common
50% by age on 50
60% living in industrialised countries
Rare below age 40
RHS diverticula more common in Asia
Lower incidence in vegetarians
What are the symptoms of diverticular disease?
Asymptomatic (80-90%)
Diverticulitis - triad
LLQ abdominal pain (70% of patients with acute diverticulitis)
Fever
High WCC
Rectal bleeding – profuse, painless, fresh
Colo-vesical fistula -> bladder
Pneumaturia
Recurrent UTI
Bloating
Constipation
What are the signs of diverticular disease?
Diverticulitis
Leukocytosis
Fever
LLQ guarding and tenderness
Distention
Pelvic tenderness on DRE
What are appropriate investigations for diverticular disease?
Bloods
FBC: leukocytosis
CT = in acute setting -> Thickening of bowel wall, abscess, streaky mesenteric fat
Other investigations
AXR
Barium (contrast) enema – CHRONIC ONLY (risk perforation) Diverticulae, abscess, perforation, obstruction, fistula
Endoscopy – colonoscopy, flexible sigmoidoscopy
Diverticulae seen, with or without mucosal inflammation Source of bleeding
Diagnostic laparoscopy
What is the management for diverticular disease?
If asymptomatic, no treatment is required
Dietary modification and fibre supplementation (Gradually increasing fibre content and hydration)
IF acute diverticulitis - AB therapy
>72 hours – oral amoxicillin OR clarithromycin + metronidazole (No improvement after 72 hours -> IV)
Analgesia
Low-residue diet (In acute phase until recovery)
IF bleeding - Endoscopic haemostasis
IF unresponsive to IV ABs, perforation, fistulae, obstruction ->Drainage or surgery – hartmann’s procedure
IF recurrent diverticulitis - Elective surgery – colectomy + primary anastamosis
What are the possible complications of diverticular disease?
Perforation Infection - diverticulitis Haemorrhage Fistula Abscess Peritonitis Colonic obstruction Colorectal neoplasm
What is the prognosis of diverticular disease?
10-25% of patients will have at least one episode of diverticulitis (1/3 of these will have a second)
Most do not require surgical intervention
¼ of surgical patients remain symptomatic
