Diverticular disease

Question 1

what is a diverticulum?

Answer 1

an outpouching of the bowel wall

Question 2

where are diverticulum most commonly found?

Answer 2

sigmoid colon

can be present throughout both large and small bowel

Question 3

what is diverticulosis?

Answer 3

presence of diverticula (asymptomatic, incidental on imaging)

Question 4

what is diverticular disease?

Answer 4

symptoms arising from diverticula

Question 5

what is diverticulitis?

Answer 5

inflammation of the diverticula

Question 6

what is a diverticular bleed?

Answer 6

where the diverticulum erodes into a vessel and causes a large volume painless bleed

Question 7

how common is diverticulosis?

Answer 7

present in around 50% of >50 yo and 7-% of >80 yo but only 25% are symptomatic
men>women
developed countries

Question 8

what is the pathophysiology of diverticula?

Answer 8

aging bowel becomes naturally weaker, movement of stool through lumen increases luminal pressure and can cause outpouching of the mucosa through the weaker areas of the bowel wall - junctions of the triangular muscle sheets and blood vessels penetrate to supply bowel wall

Question 9

what causes the inflammation in diverticulitis and what are the complications?

Answer 9

bacteria can overgrow within the outpouch causing inflammation. they can perforate - diffuse peritonitis sepsis and death
in chronic cases fistulae can from - colovesical or colovaginal

Question 10

what is the difference between simple or complicated diverticulitis?

Answer 10

complicated refers to abscess presence or free perforation whilst simple is just inflammation

Question 11

risk factors for diverticulosis?

Answer 11

age
low dietary fibre intake 
obesity
smoking 
family history 
NSAID use

Question 12

clinical features of diverticulosis

Answer 12

most asymptomatic and found incidentally

can present with diverticular disease, diverticulitis or a diverticular bleed

Question 13

features of diverticular disease

Answer 13

intermittent lower abdominal pain typically colicky in nature, relieved by defecation. 
altered bowel habit 
associated nausea 
flatulence 
no systemic features

Question 14

features of acute diverticulitis

Answer 14

acute abdominal pain typically sharp in nature and normally localised in lift iliac fossa worse on movement
localised tenderness
features of systemic upset like decreased appetite pyrexia and nausea

Question 15

how will perforated diverticulum present?

Answer 15

signs of localised peritonism or generalised peritonitis

extremely unwell and often fatal

Question 16

how are diverticular abscess’ managed

Answer 16

<5cm can generally be managed with IV ABx
any bigger - radiological drainage is first-line treatment
complicated multi-loculated abscesses may need surgery - laparoscopic ro Hartmann’s

Question 17

differentials for diverticula

Answer 17

inflammatory bowel disease

bowel cancer

Question 18

laboratory tests

Answer 18

routine bloods - FBC, CRP, U&Es
faecal calprotectin if diagnosis is less clear
G+S, venous blood gas
urine dipstick to exclude urological causes

Question 19

imaging for diverticula

Answer 19

CT abdomen-pelvis
findings suggestive of diverticulitis:
thickening of colonic wall, pericolonic fat stranding, abscesses, localised air bubbles or free air
suspected uncomplicated diverticular disease a flexible sigmoidoscopy is used to identify any obvious rectosigmoidal lesion

Question 20

how is acute diverticulitis staged?

Answer 20

Hinchey Classification - based on CT findings

Question 21

what are all the stages of the Hinchey Classification?

Answer 21

1. phlegmon (1a) or diverticulitis with pericolic or mesenteric abscess (1b)
2. diverticulitis with walled off pelvic abscess
3. diverticulitis with generalised purulent peritonitis
4. diverticulitis with generalised faecal peritonitis

Question 22

management of uncomplicated diverticular disease

Answer 22

managed as an outpatient with analgesia and encourage oral fluid intake
outpatient colonoscopy to exclude masked malignancies

Question 23

diverticular bleeds management

Answer 23

often conservatively managed as most will be self-limiting
significant bleeding will need appropriate resuscitation blood products etc
those that fail to respond to conservative management wil need embolisation or surgical resection

Question 24

how is acute diverticulitis managed

Answer 24

conservatively with Abx, IVF and analgesia
symptoms typically improve within 2-3 days after initial treatment for uncomplicated cases
clinical deterioration should prompt repeated imaging - check for disease progression

Question 25

when is surgical intervention required?

Answer 25

patients with perforation with faecal peritonitis or overwhelming sepsis
usually involves Hartmann’s procedure

Question 26

complications of diverticulitis

Answer 26

recurrence of diverticulitis - elective segmental resection may be performed
stricture or fistula formation

Question 27

what causes diverticular stricture?

Answer 27

repeated episodes of acute inflammation. bowel becomes scarred and fibrotic = benign stricture

Question 28

what can diverticular strictures result in?

Answer 28

large bowel obstruction

sigmoid colectomy is usually required either electively or urgently - depending on presentation

Question 29

2 types of fistula

Answer 29

colovesical fistula - form between bowel and bladder
generally present with recurrent UTIs, pneumoturia or passing faecal matter in the urine
colovaginal fistula - form between bowel and vagina
generally present with copious vaginal discharge or recurrent vaginal infections