Diverticular disease Flashcards
What is a diverticulum?
- Outpouching of the bowel wall
- Commonly in the sigmoid colon
- More common in men in devloped countries
What are the manifestations of diverticular disease?
- Diverticulosis - presence of diverticula
- Diverticular disease - symptomatic diverticula
- Diverticulitis - inflammation of the diverticula
- Diverticular bleed - the diverticulum erodes into a vessel and causes painless bleed
Describe the pathophysiology of diveriticular disease?
- Ageing bowel becomes weakened over time
- Movement of stool causes increased luminal pressure
- Outpouching of mucosa occurs in areas of weaker bowel wall
- Bacteria overgrowth at outpoutching causes diverticulitis (can perforate)
Describe the classification of divertiulitis?
- Simple
- Complicated
- Abscess presence, fistual formation, stricutre, perforation
Risk factors for diverticular disease?
- Low dietary fibre intake
- Obesity (younger patients)
- Smoking
- Family history
- NSAID use
What are the clinical features of diverticular disease?
- Mostly asymptomatic found incidentally on colonscopy/CT
- Diverticular pain
- Intermittent lower abdominal pain
- Colicky in nature, relieved by defaecation
- Associated nausea and flatulence
How will diverticulitis present?
- Acute abdominal pain
- Sharp in nature
- Normally localised in left iliac fossa pain
- Worsened by movement
- Features of systemic upset
- Decreased appetite
- Pyrexia
- Nausea
How will a perforated diverticulum present?
- Signs of localised peritonism or generalised peritonitis
- Patients are frequently unwell
What can mask the symptoms of diverticulitis?
- Corticosteroids
- Immunosuppressants
Complications of divertiular disease?
- Pericolic abscess
- antibiotics and bowel rest -> CT guided drainage
- Fistula formation
- Bowel obstruction
- secondary to stricture formation
- managed through stenting or bowel resection
What are the common fistula subtypes?
- Colovesical fistula
- Pneumoturia (gas in urine), faecal matter in urine, recurrent UTIs
- Colovaginal fistula
- Copious vaginal discharge, recurrent vaginal infections
- **Both require surgical resection and repair
Differentials for diverticular disease?
- Inflammatory bowel disease
- Bowel cancer
- Mesenteric ischaemia, gynaecological causes, renal stones
What investigations should be performed in someone with suspected diverticular disease?
- FBC, CRP, faecal calprotectin
- Group and save, venous blood gas, urine dipstick
- Imaging:
- CT abdomen pelvis
- ***Colonscopy should not be performed in causes of suspected diverticulitis due to increased risk of perforation
What signs on CT suggest a diagnosis of diverticulitis?
- Thickening of the colon wall
- Pericolonic fat stranding
- Abscesses
- Localised air bubbles
Describe the staging of Acute diverticulitis?
- Hinchley Classification
- Based on CT findings
- Aids clinical management
- Higher stages associated with higher morbidity/mortality
Describe the management of diverticular disease?
- Mild: analgesia and encourage oral fluid intake
- Some patients may require hospital admission for conservative or surgical management
What may warrant hospital admission in someone with diverticular disease?
- Uncontrolled pain
- Dehydration concerns
- Co-morbidities or immunocompromised
- Significant PR bleeding
Describe the convervative management of diverticular disease?
- Suspected diverticulitis
- IV antibiotics, fluids, bowel rest, analgesia
- Diverticular bleeds
- Usually self limiting
- Significant bleeding with require fluids, blood products and stabilisation
Describe the surgical management of diveriticular disease?
- Requried in those with:
- Perforation with faecal peritonitis
- Overwhelming sepsis
- Hartmann’s procedure
What are the complications of diverticulitis?
- Recurrence
- Elective segmental resection in those with recurrent disease
- A patient is admitted with extensive PR bleeding secondary to diverticulitis. Which of the following definitive management options would not be suitable?
- Discuss with interventional radiology regarding consideration for potential embolectomy
- Hartmann’s procedure
- Discharge home with analgesics and oral antibiotics
- IV antibiotics and tranfusing blood products
Discharge home with analgesics and oral antibiotics
What is a laparotomy?
Surgery which involves making a large incision in the abdominal wall to gain access to the abdominal cavity
How can the septic complications of diverticular disease be classified?
- Hinchley grading
- Grade I: Localised paracolic abscess
- Grade II: Distant abscess
- Grade III: Purulent peritonitis
- Grade IV: Faecal peritonitis
What are the main differentials for a lower GI bleed?
- Colorectal cancer / adenoma
- Angiodysplasia
- Haemorrhoids
- Diverticulitis
- Inflammatory bowel disease
What medications should be avoided in diveriticular disease due to their association with a greater risk of complications?
NSAIDs
Management of uncomplicated diverticular disease?
- High fibre diet
- Supplement methylcellulose
- Bulk forming laxative
Why is the rectum never affected by diverticular disease?
- Differences in feeding vessels
- Outer longitudinal muscle layer encompasses the full circumferance
Why can be detected before diverticular develop?
- Muscular hypertrophy
- Seen radiologically
What is the most common site for diverticulae development?
- Sigmoid colon
- High intraluminal pressure related to low fibre
