Diverticular disease

Question 1

Define:

Answer 1

GI out-pouching in the gut wall usually due to high pressures.

Can be acquired or congenital. From the oesophagus to the sigmoid colon.

Diverticulosis - this is the presence of diverticulae
Diverticulitis - this is inflammation of the diverticulae
Diverticular disease = complications due to the diverticulae such as hameorrhage, perforation and fistuale.

Question 2

Aetiology/risk factors:

Answer 2

o A low-fibre diet leads to loss of stool bulk. This leads to 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 muscle layers of the gut at weak points adjacent to penetrating vessels.

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 obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury

Question 3

Epidemiology:

Answer 3

Very common. 60% of adults in the industrialised world get diverticulae. rare in under 40’s.
Right sided common in Asia.

Question 4

Symptoms:

Answer 4

Usually asymp.
Diverticulitis (LIF pain with fever)
PR bleeding
Fistulae = facaeluria, pneumaturia, recurrent UTI’s)

Question 5

Signs:

Answer 5

If peforated: signs of generalised tenderness and peritonitis (guarding, rigidity, lying still and rebound tenderness)

Diverticulitis = tender abdomen

COMMONLY INCIDENTAL ON COLONOSCOPY.

Question 6

investigations:

Answer 6

• Bloods:
o FBC: increased WCC, increased CRP
o Check clotting and cross-match if bleeding
• Barium Enema (with or without air contrast):
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 This also risks perforation in acute setting
• In ACUTE setting: CT scan for evidence of diverticular disease and complications may be performed

Question 7

Management:

Answer 7

• Asymptomatic:
o Soluble high-fibre diet (20-30 g/day)
o Some drugs are under investigation for their use in preventing recurrent flares of diverticulitis (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 may be drained by radiologically sited drains
• Surgery:
o May be done for recurrent attacks/complications (e.g. perforation/ peritonitis)
o Open surgery:
• Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
• One-stage resection + anastomosis (risk of leak) – with/without defunctioning stoma
o Laparoscopic drainage, peritoneal lavage and drain placement can be effective

Question 8

complications:

Answer 8

• Diverticulitis
• Pericolic abscess
• Perforation
• Faecal peritonitis – faeces in peritoneal cavity
• Colonic obstruction
• Fistula formation (bladder, small intestine, vagina)
• Haemorrhage
• Post infective strictures
• Abscesses

Question 9

Prognosis:

Answer 9

10-25% will have one or more episodes