Diverticular disease

Question 1

What is diverticular disease?

Answer 1

Colonic diverticulosis refers to herniation of the mucosa and submucosa through the muscular layer of the colonic wall and may be the result of colonic smooth muscle over-activity.

Question 2

What is diverticulitis?

Answer 2

Diverticulitis indicates inflammation of a diverticulum or diverticula and may be caused by an infection.

Question 3

Difference between true and false diverticular disease

Answer 3

True- extends through the muscular layer (congenital)

False- doesn’t extend through the muscular layer (acquired)

Question 4

Causes of diverticular disease

Answer 4

Multi-factorial: 
Low dietary fibre intake
Decreased physical activity 
Obesity 
Increased red meat consumption 
Tobacco smoking 
Excessive alcohol and caffeine intake 
Steroids 
NSAIDs

Question 5

Pathophysiology of diverticular disease

Answer 5

The low-fibre diet increases intestinal transit time and decreases stool volume, resulting in increased intraluminal pressure and colonic segmentation, which predispose to the diverticular formation.
The sigmoid colon is commonly affected because of its small diameter.

Question 6

Classification of diverticular disease

Answer 6

There is no universally accepted clinical classification of diverticular disease.
-Asymptomatic diverticulosis:
Incidental finding on colonoscopy, barium enema or CT scan
-Symptomatic uncomplicated diverticular disease:
Painful diverticular disease
Episodic left-lower abdominal colicky pain
Non-specific symptoms: Bloatedness, constipation and diarrhoea
- Complicated diverticular disease:
Most common complication is acute diverticulitis

Question 7

Complications of complicated diverticular disease

Answer 7

Diverticulitis 
Haemorrhage 
Abscess 
Segmental colitis 
Diverticular phlegmon 
Perforation 
Peritonitis 
Fistula 
Stricture 
Obstruction

Question 8

Hinchey’s classification of diverticular disease

Answer 8

Stage I- small or confined paracolic or mesenteric abscess
Stage II- large paracolic abscess often extending into the pelvis
Stage III- Perforated diverticulitis where a peri-diverticular abscess has perforated
Stage IV- Perforated diverticulitis where there is free perforation and is associated with faecal peritonitis

Question 9

Signs and symptoms of diverticular disease

Answer 9

Left LUQ pain 
Leukocytosis 
Fever (common)
Rectal bleeding (common) 
Bloating 
Constipation 
Pelvic tenderness on DRE (common)

Question 10

Risk factors of diverticular disease

Answer 10

Low dietary fibre
Age > 50 years
Western diet
NSAID use

Question 11

Tests of diverticular disease

Answer 11

FBC with differential (polymorphonuclear leukocytosis)
AXR (if acute diverticulitis is suspected)
CT scan of the abdomen (thickening of the bowel wall, mass, abscess)
Abdominal ultrasound (graded-compression)
CXR (normal or free air under diaphragm if perforation)
Colonoscopy
Sigmoidoscopy

Question 12

Differentials of diverticular disease

Answer 12

Endometriosis 
Appendicitis 
Crohn's disease 
Pyelonephritis 
Pelvic inflammatory disease 
Colorectal cancer 
Ulcerative colitis 
UTIs 
Ischaemic colitis 
IBS

Question 13

Management of diverticular disease

Answer 13

Asymptomatic diverticulosis- No treatment required
Symptomatic diverticular disease-
Dietary modification + fibre supplementation
Oral antibiotic therapy
Symptomatic diverticulitis (complicated)Acute rectal bleeding-
Endoscopic haemostasis
Supportive therapy + antibiotics (amoxicillin)
Analgesia
Low-residue diet
Symptomatic diverticulitis (unresponsive to IV antibiotics or with abscess >3cm):
1st line:
Radiological drainage/surgery
IV antibiotics therapy
Analgesia
Low-residue diet
Recurrent diverticulitis- elective surgery (colectomy)