Diverticular Disease Flashcards
Define Diverticulosis?
The presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
Define Diverticular Disease?
Diverticulosis associated with complications e.g. haemorrhage, infection, fistulae
What is Diverticulitis?
Acute inflammation and infection of colonic diverticulae
What is the Hinchey Classification of Acute Diverticulitis?
Ia: phlegmon
Ib and II: localised abscesses
III: perforation and purulent peritonitis
IV: faecal peritonitis
What is the aetiology of Diverticular Disease?
A low-fibre diet leads to loss of stool bulk
This leads to the generation of high colonic intraluminal pressures to propel the stool out
This, in turn, leads to the herniation of the mucosa and submucosa through the muscularis
What is the pathogenesis of Diverticular Disease?
Diverticulae are most commonly found in the sigmoid and descending colon
However, they can also be right-sided
Diverticulae are NOT found in the rectum
Diverticulae are found particularly at sites of nutrient artery penetration
Diverticular obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury
Which can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation or stricture formation
What is the epidemiology of Diverticular Disease?
Diverticular Disease is VERY COMMON
60% of people living in industrialised countries will develop colonic diverticulae
Rare < 40 years
Right-sided diverticulae are more common in Asia
What percentage of cases of Diverticular Disease are Asymptomatic?
80-90%
What are some of the symptoms of Diverticular Disease caused by complications?
PR Bleeding
Diverticulitis symptoms
Diverticular Fistulation symptoms
What are Diverticulitis Symptoms?
Causing LIF and lower abdominal pain and fever
What are Diverticular Fistulation symptoms?
Causing pneumaturia, faecaluria and recurrent UTI
What are the signs of Diverticular Disease on physical examination?
Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated
What bloods would you do for Diverticular Disease?
FBC - increased WCC and increased CRP
Check clotting and cross-match if bleeding
Why do we do a Barium Enema (with or without air contrast) for Diverticular Disease?
Shows presence of diverticulae (saw-tooth apperance of lumen)
This reflects pseudohypertrophy of circular muscle
When should Barium Enema not be performed?
In the acute setting, because there is a high risk of perforation
Why do we do Flexible Sigmoidoscopy and Colonoscopy for Diverticular Disease?
Diverticulae can be visualised and other pathology (e.g. polyps and tumours) can be excluded
What investigation do we do in an acute setting for Diverticular Disease?
CT scan for evidence of Diverticular Disease and complications may be performed
What is the management plan for Asymptomatic Diverticular Disease?
Soluble high-fibre diet (20-30 g/day)
Some drugs are under investigation for their use in preventing recurrent flares of diverticulitis (such as probiotics and anti-inflammatories)
What is the management plan for GI bleeds in Diverticular Disease?
PR bleeding usually managed conservatively with IV rehydration, antibiotics and blood transfusion if necessary
Angiography and embolisation or surgery if severe
What is the management plan if Diverticulitis occurs in Diverticular Disease?
IV antibiotics
IV fluid rehydration
Bowel rest
Abscesses may be drained by radiologically sited drains
When may surgery be necessary in Diverticular Disease?
In patients with recurrent attacks or complications (e.g. perforation and peritonitis)
What are the two types of Open surgery you can do for Diverticular Disease?
Hartmann’s Procedure (proctosigmoidectomy leaving a stoma)
One-stage resection and anastomosis (risk of leak) - with or without defunctioning stoma
What are some of the other surgical procedures that can be used for Diverticular Disease?
Laparoscopic drainage, peritoneal lavage and drain placement can be effective
What are the possible complications of Diverticular Disease?
Diverticulitis Pericolic Abscess Perforation Faecal Peritonitis Colonic Obstruction Fistula formation (bladder, small intestine, vagina) Haemorrhage
What is the prognosis for patients with Diverticular Disease?
10-25% have one or more episodes of diverticulitis
