Diverticular disease

Question 1

Define diverticular disease

Answer 1

Diverticulosis – presence of diverticulae (outpouchings of the colonic mucosa and
submucosa through the muscular wall); diverticulae are most common in the sigmoid and descending colon but can be right sided

Diverticular disease – diverticulosis and its associated complications (symptomatic)

Diverticulitis – acute inflammation and infection of colonic diverticulae

Question 2

What are the causes/risk factors of diverticular disease?

Answer 2

• Low dietary fibre (Western diet)
• Age >50 years
• Obesity
• Low Physical Activity
• Red Meat (less common in vegetarians)
• NSAIDs and Steroids
• Alcohol and Caffeine

Low dietary fibre intake -> low volume stool requiring higher intraluminal pressure to
propel stool through the bowel -> herniation of the mucosa and submucosa
through the muscular layer particularly between the taenia coli. Inspissated food or faecal
matter can cause diverticular obstruction -> bacterial overgrowth, toxin production and
mucosal injury -> diverticulitis

Question 3

What are the symptoms of diverticular disease?

Answer 3

• Asymptomatic (80-90%)
• LLQ pain (colicky)
• Bloating/flatulence
• Constipation
• Fever

Question 4

What are the signs of diverticular disease?

Answer 4

• LLQ guarding and tenderness

Question 5

What investigations are carried out for diverticular disease?

Answer 5

• FBC - leucocytosis and raised granulocytes (mainly neutrophils).
• CRP - elevated
• Coagulation Screen - to assess if there is an underlying reason for persistent bleeding.
• Cross Match - in persistent bleeding for blood transfusion.
• Blood Culture - if septic: usually gram negative rods, and anaerobic bacteria; obtain prior to administration of antibiotics
• CXR - if perforation and peritonitis to visualise pneumoperitoneum.
• AXR - to visualise pneumoperitoneum and ileus
• CT Abdomen - barium Enema ± Air Contrast - can be used to visualise diverticula, abscesses, perforation, obstruction, fistulae.
• Colonoscopy - single, multiple, or scattered diverticula, with or without acute mucosal inflammation. It can localise the source of bleeding, can also show co-existing pathologies e.g. neoplasms, which need to be excluded.
• Sigmoidoscopy - same as colonoscopy

Question 6

What is the management for diverticular disease?

Answer 6

Asymptomatic Diverticulosis:
• Conservative: High dietary fibre and fibre supplements.
• Medical: Probiotics and mesalazine used prophylactically to prevent diverticulitis.

Diverticulitis (Uncomplicated):
• Conservative: High dietary fibre and fibre supplements.
• Medical:
- Oral antibiotics –metronidazole, ciprofloxacin or co-amoxiclav. IV antibiotics are second line.
- Analgesia: Paracetamol. (Tramadol and Morphine if severe pain).

Complications:
• PR Bleeding:
- IV Rehydration and blood transfusion.
- Endoscopic haemostasis or Angiographic Embolisation; Diathermy; Local adrenaline injection.
- Surgery may be required if other measures cannot stop the bleeding.

Perforation and Peritonitis: Surgery (Open or Laparoscopic)
• Open: Hartmann’s procedure (resection and stoma) or one-stage resection and anastomosis (risk of leak) ± defunctioning stoma.
• Laparoscopic: Drainage, peritoneal lavage and drain placement.

Recurrent diverticulitis: Elective colectomy.

Question 7

What are the complications of diverticular disease?

Answer 7

• Diverticulitis
• Pericolic abscess
• Perforation
• Faecal peritonitis
• Colonic obstruction
• Fistulae
- Bladder -> pneumaturia, faecaluria, recurrent UTI
- Small intestine
- Vagina
• Haemorrhage
• Strictures