Diverticular Disease

Question 1

What is Diverticular Disease?

Answer 1

• Condition in which diverticula develop in the large bowel, most commonly in the sigmoid colon

Diverticula is a pouch of colonic mucosa that has herniated through the muscularis propria

Diverticulosis = asymptomatic

Question 2

Why are diverticula most likely to form in the sigmoid colon?

Answer 2

Sigmoid colon has the smallest diameter of the entire colon therefore diverticula most likely to form there

Question 3

What are the risk factor of Diverticular Disease?

Answer 3

• Age (> 60)
• Obesity
• Smoking
• Lack of exercise
• Weakness of bowel wall
• Diet low in fibre

Question 4

What is the differential diagnosis of Diverticular Disease?

Answer 4

• Colorectal cancer
• Endometeriosis
• Appendicitis
• Irritable Bowel Syndrome (IBS)

Question 5

What are the causes of Diverticular Disease?

Answer 5

• Low dietary fibre intake
• Decreased physical activity
• Obesity
• Weakness in colonic wall structure
• Abnormal colonic motility
• Smoking and/or alcohol
• Colonic neurotransmitter dysfunction

Question 6

What are the 2 common clinical features of Diverticular Disease?

Answer 6

Diverticulosis - diverticular present but asymptomatic

Diverticulitis - acutely inflamed diverticulum

Question 7

What are the clinical features of Acute Diverticulitis?

Answer 7

• Malaise
• Fever
• Abdominal pain
• Lower GI bleeding (often resolve simultaneously in diverticular bleeds)
• Faecaluria through fistula formation

Question 8

What are the 2 factors important in diverticula formation?

Answer 8

• Areas of weakness in the colonic wall

- Raised intra-luminal pressure

Question 9

What is the main cause of raised intra-luminal pressure?

Answer 9

=> Low fibre in take:

• Movement of faeces requires greater muscular effort
• Results in muscle hypertrophy, lower luminal diameter
• Low lumen diameter = increased intra-luminal pressure

Question 10

How does bacterial peritonitis occur in Diverticular Disease?

Answer 10

• Abscess formation

- May perforate

Question 11

What are the investigations in suspected Diverticular Disease?

Answer 11

=> Colonoscopy

=> CT Abdomen with IV contrast
- Used to confirm Acute Diverticulitis and monitor fistulas

=> AXR
Identifies any obstruction

=> Biopsy
To rule out Colorectal Cancer

=> Acute unwell patients may be given plain abdominal films and erect CXR to identify any perforation

Question 12

What is the management of Diverticular Disease?

Answer 12

Need for surgery is determined by degree of infective complications

=> STAGE 1

• Pericolic and mesenteric abscess
• Surgery rarely required

=> STAGE 2

• Walled off or pelvic abscess
• May resolve without surgery

=> STAGE 3

• Generalised purulent peritonitis
• Surgery required

=> STAGE 4

• Generalised faecal peritonitis
• Surgery required

=> Management:

• Increased fibre intake
• Mild attacks of diverticulitis may be managed with PO antibiotics
• If symptoms don’t settle within 72 hours, hospital admission with IV antibiotics, IV fluids and IV analgesia required
• Peri colic abscesses should be drained surgically or radiologically
• Recurrent episodes of diverticulitis are an indication of surgical resection
• Stage 4 defo require resection