Diverticular disease Flashcards
What is a diverticulum?
Outpouching of the gut wall
Can occur at any level from the oesophagus to the colon
Acquired or congenital.
What is diverticulosis?
Presence of diverticulae outpouchings of the colonic mucosa + submucosa through the muscular wall of the large bowel
What is diverticular disease?
diverticulosis associated with complications e.g. haemorrhage, infection, fistulae
What is diverticulitis?
acute inflammation + infection of colonic diverticulae
Describe the aetiology of diverticular disease
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.
Describe the epidemiology of diverticular disease
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
Describe the Hinchey Classification of Acute Diverticulitis
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.
How may diverticular disease present?
Asymptomatic (80-90%)
Commonly an incidental finding at colonoscopy
What symptoms may arise from complications of diverticular disease?
PR bleeding: Blood supply to colon is where outpouches occur so bleeds a lot
What drug may provoke bleeding in diverticular disease?
NSAIDs
Give 2 symptoms of diverticulitis
LIF + Lower abdo pain
Fever
List 3 signs of diverticular fistulation
Pneumaturia
Faecaluria
Recurrent UTI
Give 2 signs of diverticulitis
Tender abdomen
Signs of local or generalised peritonitis if a diverticulum has perforated
Give 3 risk factors for diverticular disease
Low fibre diet
Increasing age
Obesity
Describe the distribution of diverticular disease
Most commonly found in sigmoid + descending colon but also be right-sided
NOT found in the rectum
Often at sites of nutrient artery penetration
What bloods are seen/ taken in diverticular disease?
Increased WCC
Increased CRP
Check clotting +cross-match if bleeding
What may be seen on Barium enema (with or without air contrast) in diverticular disease?
Presence of diverticulae (saw-tooth appearance of lumen)
Reflects pseudohypertrophy of circular muscle
Why should Barium enema or colonoscopy not be performed in the acute setting of diverticular disease?
High risk of perforation
Why perform Flexible Sigmoidoscopy and Colonoscopy in diverticular disease?
Diverticulae can be visualised Other pathology (e.g. polyps + tumours) can be excluded
What investigation should be performed in the acute setting in diverticular disease?
CT scan for evidence of diverticular disease + complications
Describe the management of asymptomatic (chronic) diverticular disease
Soluble high-fibre diet (20-30 g/day)
Some drugs may prevent recurrent flares of diverticulitis (probiotics + anti-inflammatories e.g. mesalazine)
Describe the management of a GI bleed in diverticular disease
PR bleeding usually managed conservatively with IV rehydration, Abx + blood transfusion if necessary
Angiography + embolisation or surgery if severe
Describe management of diverticulitis
IV Abx
IV fluid rehydration
Bowel rest
Abscesses may be drained by radiologically sited drains
In what setting should acute diverticulitis be managed?
MILD: managed with oral Abx, liquid diet + analgesia
SEVERE/ If Sx don’t settle within 72 hours: Admit to hospital for IV Abx
When may surgery be considered for diverticular disease?
For recurrent attacks (2 eps requiring hospital admin)/ complications (e.g. obstructed bowel/ perforation/ peritonitis)
Describe surgical management of diverticular disease
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
List 9 complications of diverticular disease
Diverticulitis Pericolic abscess Perforation Faecal peritonitis: faeces in peritoneal cavity Colonic obstruction Fistula formation (bladder, small intestine, vagina) Haemorrhage Post infective strictures Abscesses
What is the prognosis of diverticular disease?
10-25% have one or more episodes of diverticulitis
What occurs when diverticular are obstructed by thickened faeces
Bacterial overgrowth, toxin production + mucosal injury
Can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration + fistulation or stricture formation
