Diverticular disease Flashcards
what is a diverticulum?
an outpouching of the bowel wall
where are diverticulum most commonly found?
sigmoid colon
can be present throughout both large and small bowel
what is diverticulosis?
presence of diverticula (asymptomatic, incidental on imaging)
what is diverticular disease?
symptoms arising from diverticula
what is diverticulitis?
inflammation of the diverticula
what is a diverticular bleed?
where the diverticulum erodes into a vessel and causes a large volume painless bleed
how common is diverticulosis?
present in around 50% of >50 yo and 7-% of >80 yo but only 25% are symptomatic
men>women
developed countries
what is the pathophysiology of diverticula?
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
what causes the inflammation in diverticulitis and what are the complications?
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
what is the difference between simple or complicated diverticulitis?
complicated refers to abscess presence or free perforation whilst simple is just inflammation
risk factors for diverticulosis?
age low dietary fibre intake obesity smoking family history NSAID use
clinical features of diverticulosis
most asymptomatic and found incidentally
can present with diverticular disease, diverticulitis or a diverticular bleed
features of diverticular disease
intermittent lower abdominal pain typically colicky in nature, relieved by defecation. altered bowel habit associated nausea flatulence no systemic features
features of acute diverticulitis
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
how will perforated diverticulum present?
signs of localised peritonism or generalised peritonitis
extremely unwell and often fatal
how are diverticular abscess’ managed
<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
differentials for diverticula
inflammatory bowel disease
bowel cancer
laboratory tests
routine bloods - FBC, CRP, U&Es
faecal calprotectin if diagnosis is less clear
G+S, venous blood gas
urine dipstick to exclude urological causes
imaging for diverticula
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
how is acute diverticulitis staged?
Hinchey Classification - based on CT findings
what are all the stages of the Hinchey Classification?
- phlegmon (1a) or diverticulitis with pericolic or mesenteric abscess (1b)
- diverticulitis with walled off pelvic abscess
- diverticulitis with generalised purulent peritonitis
- diverticulitis with generalised faecal peritonitis
management of uncomplicated diverticular disease
managed as an outpatient with analgesia and encourage oral fluid intake
outpatient colonoscopy to exclude masked malignancies
diverticular bleeds management
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
how is acute diverticulitis managed
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
when is surgical intervention required?
patients with perforation with faecal peritonitis or overwhelming sepsis
usually involves Hartmann’s procedure
complications of diverticulitis
recurrence of diverticulitis - elective segmental resection may be performed
stricture or fistula formation
what causes diverticular stricture?
repeated episodes of acute inflammation. bowel becomes scarred and fibrotic = benign stricture
what can diverticular strictures result in?
large bowel obstruction
sigmoid colectomy is usually required either electively or urgently - depending on presentation
2 types of fistula
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
