Diverticular Disease

Question 1

Define Diverticulosis?

Answer 1

The presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel

Question 2

Define Diverticular Disease?

Answer 2

Diverticulosis associated with complications e.g. haemorrhage, infection, fistulae

Question 3

What is Diverticulitis?

Answer 3

Acute inflammation and infection of colonic diverticulae

Question 4

What is the Hinchey Classification of Acute Diverticulitis?

Answer 4

Ia: phlegmon
Ib and II: localised abscesses
III: perforation and purulent peritonitis
IV: faecal peritonitis

Question 5

What is the aetiology of Diverticular Disease?

Answer 5

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

Question 6

What is the pathogenesis of Diverticular Disease?

Answer 6

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

Question 7

What is the epidemiology of Diverticular Disease?

Answer 7

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

Question 8

What percentage of cases of Diverticular Disease are Asymptomatic?

Answer 8

80-90%

Question 9

What are some of the symptoms of Diverticular Disease caused by complications?

Answer 9

PR Bleeding
Diverticulitis symptoms
Diverticular Fistulation symptoms

Question 10

What are Diverticulitis Symptoms?

Answer 10

Causing LIF and lower abdominal pain and fever

Question 11

What are Diverticular Fistulation symptoms?

Answer 11

Causing pneumaturia, faecaluria and recurrent UTI

Question 12

What are the signs of Diverticular Disease on physical examination?

Answer 12

Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated

Question 13

What bloods would you do for Diverticular Disease?

Answer 13

FBC - increased WCC and increased CRP

Check clotting and cross-match if bleeding

Question 14

Why do we do a Barium Enema (with or without air contrast) for Diverticular Disease?

Answer 14

Shows presence of diverticulae (saw-tooth apperance of lumen)
This reflects pseudohypertrophy of circular muscle

Question 15

When should Barium Enema not be performed?

Answer 15

In the acute setting, because there is a high risk of perforation

Question 16

Why do we do Flexible Sigmoidoscopy and Colonoscopy for Diverticular Disease?

Answer 16

Diverticulae can be visualised and other pathology (e.g. polyps and tumours) can be excluded

Question 17

What investigation do we do in an acute setting for Diverticular Disease?

Answer 17

CT scan for evidence of Diverticular Disease and complications may be performed

Question 18

What is the management plan for Asymptomatic Diverticular Disease?

Answer 18

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)

Question 19

What is the management plan for GI bleeds in Diverticular Disease?

Answer 19

PR bleeding usually managed conservatively with IV rehydration, antibiotics and blood transfusion if necessary
Angiography and embolisation or surgery if severe

Question 20

What is the management plan if Diverticulitis occurs in Diverticular Disease?

Answer 20

IV antibiotics
IV fluid rehydration
Bowel rest
Abscesses may be drained by radiologically sited drains

Question 21

When may surgery be necessary in Diverticular Disease?

Answer 21

In patients with recurrent attacks or complications (e.g. perforation and peritonitis)

Question 22

What are the two types of Open surgery you can do for Diverticular Disease?

Answer 22

Hartmann’s Procedure (proctosigmoidectomy leaving a stoma)

One-stage resection and anastomosis (risk of leak) - with or without defunctioning stoma

Question 23

What are some of the other surgical procedures that can be used for Diverticular Disease?

Answer 23

Laparoscopic drainage, peritoneal lavage and drain placement can be effective

Question 24

What are the possible complications of Diverticular Disease?

Answer 24

Diverticulitis 
Pericolic Abscess 
Perforation
Faecal Peritonitis 
Colonic Obstruction
Fistula formation (bladder, small intestine, vagina)
Haemorrhage

Question 25

What is the prognosis for patients with Diverticular Disease?

Answer 25

10-25% have one or more episodes of diverticulitis