Diverticular Disease Flashcards
Definition
• It is important to distinguish between the different terms used when discussing patients with diverticular disease
o Diverticulosis: the presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
o Diverticular Disease: diverticulosis associated with complications e.g. haemorrhage, infection,
fistulae
o Diverticulitis: acute inflammation and infection of colonic diverticulae
Hinchey classification
o Hinchey Classification of Acute Diverticulitis:
- Ia: phlegmon
- Ib and II: localised abscesses
- III: perforation and purulent peritonitis
- IV: faecal peritonitis
Aetiology
o A low-fibre diet leads to loss of stool bulk
o This leads to the generation of high colonic intraluminal pressures to propel the stool out
o This, in turn, leads to the herniation of the mucosa and submucosa through the muscularis
Pathogenesis
o Diveticulae are most commonly found in the sigmoid and descending colon
o However, they can also be right-sided
o Diverticulae are NOT found in the rectum
o Diverticular are found particularly at sites of nutrient artery penetration
o Diverticular obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury
o Which can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation or stricture formation
Epidemiology
· Diverticular disease is VERY COMMON
· 60% of people living in industrialised countries will develop colonic diverticulae
· Rare < 40 yrs
· Right-sided diverticulae are more common in Asia
Presenting symptoms
· Often ASYMPTOMATIC (80-90%)
· Complications can lead to symptoms such as:
o PR bleeding
o Diverticulitis (causing LIF and lower abdominal pain and fever)
o Diverticular fistulation (causing pneumaturia, faecaluria and recurrent UTI)
Signs on physical examination
· Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated
Investigations (bloods)
o FBC: increased WCC, increased CRP
o Check clotting and cross-match if bleeding
Investigations (other)
· Barium Enema (with or without air contrast):
o Shows presence of diverticulae (saw-tooth appearance of lumen)
o This reflects pseudohypertrohy of circular muscle
o IMPORTANT: barium enema should NOT be performed in the acute setting because there is a high risk of perforation
· Flexible Sigmoidoscopy and Colonoscopy:
o Diverticulae can be visualised and other pathology (e.g. polyps and tumours) can be excluded
· In ACUTE setting: CT scan for evidence of diverticular disease and complications may be performed
Management plan (asymptomatic)
o Soluble high-fibre diet (20-30 g/day)
o Some drugs are under investigation for their use in preventing recurrent flares of diverticulitis (such as probiotics and anti-inflammatories)
Management plan (GI bleed)
o PR bleeding usually managed conservatively with IV rehydration, antibiotics and blood transfusion if necessary
o Angiography and embolisation or surgery if severe
Management plan (diverticulitis)
o IV antibiotics
o IV fluid rehydration
o Bowel rest
o Abscesses ma be drained by radiologically sited drains
Management plan (surgery)
o May be necessary in patients with recurrent attacks or complications (e.g. perforation and peritonitis)
o Open surgery:
· Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
· One-stage resection and anastomosis (risk of leak) - with or without defunctioning stoma
o Laparoscopic drainage, peritoneal lavage and drain placement can be effective
Possible complications
· Diverticulitis · Pericolic abscess · Perforation · Faecal peritonitis · Colonic obstruction · Fistula formation (bladder, small intestine, vagina) · Haemorrhage
Prognosis
10-25% have one or more episodes of diverticulitis
