diverticular disease

Question 1

definition

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. Diverticular disease may be defined as any clinical state caused by symptoms pertaining to colonic diverticula and includes a wide-ranging spectrum from asymptomatic to severe and complicated disease. Diverticulitis indicates inflammation of a diverticulum or diverticula and may be caused by infection. Other complications of diverticular disease include segmental colitis, lower gastrointestinal bleeding, infection, abscess, perforation, peritonitis, fistula formation, and obstruction.

Question 2

diverticulosis/diverticular disease/diverticulitis

Answer 2

• Diverticulosis: The presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel.
• Diverticular disease: Diverticulosis associated with complications, e.g. haemorrhage, infection, fistulae.
• Diverticulitis: Acute inflammation and infection of colonic diverticulae.
• Hinchey classification of acute diverticulitis: Ia: phlegmon, Ib and II: localized abscesses,
  III: perforation with purulent peritonitis or IV: faecal peritonitis.

Question 3

cause

Answer 3

A low-fibre diet leads to loss of stool bulk. Consequently, high colonic intraluminal pressures must be generated to propel the stool, leading to herniation of the mucosa and submucosa through the muscularis.

Diverticulae are most common in the sigmoid and descending colon but can be right sided. Absent from the rectum. Diverticulae consist of herniated mucosa and submucosa through the muscularis, particularly at sites of nutrient artery penetration. Proposed diverticular obstruction by inspissated faeces can lead to bacterial overgrowth, toxin production and mucosal injury and diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation or stricture formation.

Question 4

symptoms

Answer 4

often asymptomatic! (80-90%)
Complications include: pr bleeding, bloating, constipation
Diverticulitis: typically, left iliac fossa or lower abdominal pain, fever
Diverticular fistulation into bladder: pneumaturia, faecaluria and recurrent UTI.

Question 5

signs

Answer 5

Diverticulitis: Tender abdomen; signs of local or generalized peritonitis if perforation has occurred.

Question 6

investigations

Answer 6

1st investigation:
- FBC (Polymorphonuclear leukocytosis is present in acute diverticulitis. When leukocytosis is present in older patients with a history of diverticulosis, the diagnosis is probably acute diverticulitis. FBC results should be considered at the first encounter with a patient when diverticulitis is suspected.)

others:

• abdo x ray
• CT abdo
• USS abdo
• CXR => check for possible pneumoperitoneum (air bubble) in people with suspected perforation.
• contrast enema
• colonscopy/sigmoidoscopy (when diagnosis of diverticular disease is unclear and cancer or bowel ischaemia is suspected. Can be used for accurate diagnosis in acute bleeding)

Question 7

risk factors

Answer 7

• low dietary fibre

- > 50 y/o

Question 8

treatment

Answer 8

asymptomatic diverticular disease: no treatment needed

symptomatic diverticular disease:
1. dietary modification + fibre supplementation
+ oral antibiotics (amoxiclav OR ciprofloxacin+metridonazole)

symptomatic diverticulitis, uncomplicated:
1. analgesia
+ oral antibiotics (amoxiclav OR ciprofloxacin+metronidazole)
+ low residue diet
2. IV antibiotics (ceftriaxone+metronidazole) – Intravenous antibiotics are used if there is no improvement 72 hours after oral antibiotics have been started, or if symptoms of acute diverticulitis or acute abdomen present and/or fever and leukocytosis persist
+ analgesia
+ low residue diet

symptomatic diverticulitis, complicated
with acute rectal bleeding:
1. endoscopic haemostasis/angiographic embolisation
+ supportive therapy
+ antibiotics (amoxiclav OR ciprofloxacin+metronidazole)
+ analgesia
+ low residue diet
2. surgery – when major haemorrhage is not controlled by endoscopic and angiographic treatment
+ (everything above)

unresponsive to IV antibiotics of with abscess >3cm diameter, perforation, fistulae, or obstruction:
1. radiological (CT/USS guided) drainage/surgery
+ IV antibiotics (ceftriaxone + metronidazole)
+ analgesia
+ low residue diet

(non acute) recurrent diverticulitis:
1. elective surgery