Diverticular disease

Question 1

What is a diverticulum?

Answer 1

Outpouching of the gut wall
Can occur at any level from the oesophagus to the colon
Acquired or congenital.

Question 2

What is diverticulosis?

Answer 2

Presence of diverticulae outpouchings of the colonic mucosa + submucosa through the muscular wall of the large bowel

Question 3

What is diverticular disease?

Answer 3

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

Question 4

What is diverticulitis?

Answer 4

acute inflammation + infection of colonic diverticulae

Question 5

Describe the aetiology of diverticular disease

Answer 5

Low-fibre diet leads to loss of stool bulk.
Requires high colonic intraluminal pressures to propel the stool out
This leads to herniation of the mucosa + submucosa through muscle layers of the gut at weak points adjacent to penetrating vessels.

Question 6

Describe the epidemiology of diverticular disease

Answer 6

VERY COMMON.
60% of HIC develop colonic diverticulae
Rare < 40 yrs.
Right-sided diverticulae are more common in Asia
Perforated diverticulitis is common in Western societies

Question 7

Describe the Hinchey Classification of Acute Diverticulitis

Answer 7

Ia: phlegmon: spreading diffuse inflammatory process with formation of purulent exudate
Ib + II: localised abscesses
III: perforation + purulent peritonitis
IV: faecal peritonitis: faeces in peritoneal cavity, due to LB perforation.

Question 8

How may diverticular disease present?

Answer 8

Asymptomatic (80-90%)

Commonly an incidental finding at colonoscopy

Question 9

What symptoms may arise from complications of diverticular disease?

Answer 9

PR bleeding: Blood supply to colon is where outpouches occur so bleeds a lot

Question 10

What drug may provoke bleeding in diverticular disease?

Answer 10

NSAIDs

Question 11

Give 2 symptoms of diverticulitis

Answer 11

LIF + Lower abdo pain

Fever

Question 12

List 3 signs of diverticular fistulation

Answer 12

Pneumaturia
Faecaluria
Recurrent UTI

Question 13

Give 2 signs of diverticulitis

Answer 13

Tender abdomen

Signs of local or generalised peritonitis if a diverticulum has perforated

Question 14

Give 3 risk factors for diverticular disease

Answer 14

Low fibre diet
Increasing age
Obesity

Question 15

Describe the distribution of diverticular disease

Answer 15

Most commonly found in sigmoid + descending colon but also be right-sided
NOT found in the rectum
Often at sites of nutrient artery penetration

Question 16

What bloods are seen/ taken in diverticular disease?

Answer 16

Increased WCC
Increased CRP
Check clotting +cross-match if bleeding

Question 17

What may be seen on Barium enema (with or without air contrast) in diverticular disease?

Answer 17

Presence of diverticulae (saw-tooth appearance of lumen)

Reflects pseudohypertrophy of circular muscle

Question 18

Why should Barium enema or colonoscopy not be performed in the acute setting of diverticular disease?

Answer 18

High risk of perforation

Question 19

Why perform Flexible Sigmoidoscopy and Colonoscopy in diverticular disease?

Answer 19

Diverticulae can be visualised
Other pathology (e.g. polyps + tumours) can be excluded

Question 20

What investigation should be performed in the acute setting in diverticular disease?

Answer 20

CT scan for evidence of diverticular disease + complications

Question 21

Describe the management of asymptomatic (chronic) diverticular disease

Answer 21

Soluble high-fibre diet (20-30 g/day)

Some drugs may prevent recurrent flares of diverticulitis (probiotics + anti-inflammatories e.g. mesalazine)

Question 22

Describe the management of a GI bleed in diverticular disease

Answer 22

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

Question 23

Describe management of diverticulitis

Answer 23

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

Question 24

In what setting should acute diverticulitis be managed?

Answer 24

MILD: managed with oral Abx, liquid diet + analgesia

SEVERE/ If Sx don’t settle within 72 hours: Admit to hospital for IV Abx

Question 25

When may surgery be considered for diverticular disease?

Answer 25

For recurrent attacks (2 eps requiring hospital admin)/ complications (e.g. obstructed bowel/ perforation/ peritonitis)

Question 26

Describe surgical management of diverticular disease

Answer 26

Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
One-stage resection + anastomosis (risk of leak) with or without defunctioning stoma
Laparoscopic drainage, peritoneal lavage + drain placement

Question 27

List 9 complications of diverticular disease

Answer 27

Diverticulitis  
Pericolic abscess  
Perforation  
Faecal peritonitis: faeces in peritoneal cavity 
Colonic obstruction  
Fistula formation (bladder, small intestine, vagina)  
Haemorrhage  
Post infective strictures 
Abscesses

Question 28

What is the prognosis of diverticular disease?

Answer 28

10-25% have one or more episodes of diverticulitis

Question 29

What occurs when diverticular are obstructed by thickened faeces

Answer 29

Bacterial overgrowth, toxin production + mucosal injury
Can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration + fistulation or stricture formation