Diverticular disease Flashcards
Define Diverticular disease, diverticulosis and diverticulitis
Diverticular disease = Diverticulosis + complications e.g. haemorrhage, infection, fistulae
Diverticulosis = Presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
Diverticulitis = acute inflammation and infection of colonic diverticulae
What classification system is used for Diverticular disease
Hinchey classification
Ia: Phlegmon
Ib and II: localised abscesses
III: perforation + purulent peritonitis
IV: faecal peritonitis
Aetiology of Diverticular disease
Predominant contributing factor (Western) = Low dietary fibre (Loss of stool bulk => high intraluminal pressures => herniation of mucosa submucosa through muscularis)
Others: Reduced physical activity Obesity Red meat Smoking Alcohol and caffeine Steroids, NSAIDs Ehlers-Danlos syndrome
Where is diverticular disease most common
Sigmoid colon
+ descending colon
Risk factors for Diverticular disease
Low dietary fibre Age >50 years Western diet Obesity NSAID use
Symptoms of Diverticular disease
Often asymptomatic
Bloody stool LIF pain Fever Urinary symptoms (fistulation into the bladder -> pneumaturia, faecalcuria, recurrent UTIs Bloating Constipation
Signs of Diverticular disease on examination
LIF pain, guarding and tenderness Fever Pelvic tenderness on DRE Palpable abdominal mass Diffuse abdominal tenderness
Investigations for Diverticular disease
CT abdomen: outpouchings + thickening of bowel wall, mass, abscess, streaky mesenteric fat
AXR: pneumoperitoneum, ileus, soft tissue densities, free air (bowel perforation)
FBC: leucocytosis
CRP: raised
Clotting: high bleeding risk
X-match: high bleeding risk
CXR: Assess for perforation (pneumoperitoneum)
Barium enema: presence of diverticular + saw-tooth appearance of lumen + abscess, perforation, obstruction
Sigmoidoscopy/colonoscopy: diverticulae seen
Management for asymptomatic and symptomatic diverticular disease
Asymptomatic: No treatment required
Symptomatic:
Dietary modification + fibre supplements
Oral antibiotics e.g. amoxicillin
Colonoscopy in 6-8 weeks to check for malignancy
Management for uncomplicated and complicated diverticulitis
Uncomplicated
Analgesia e.g. paracetamol
Oral antibiotics e.g. amoxicillin => IV antibiotic e.g. ceftriaxone
Low-residue diet
Complicated Endoscopic haemostasis (massive GI bleed) Oral antibiotics e.g. amoxicillin Fluid infusion/blood transfusion Analgesia e.g. paracetamol Low-residue diet + bowel rest
Management for recurrent diverticulitis
Surgery - colectomy (open or laparascopic)
Open: Hartmann’s procedure (resection + stoma)
Laprascopic: drainage, peritoneal lavage + drain placement
Complications of Diverticular disease
Diverticulitis Fistulae Colorectal neoplasm Abscess Perforation Strictures + obstruction Faecal peritonitis
Prognosis for Diverticular disease
Uncomplicated will recover after treatment
Recurs in 1/3 patients
Risk of recurrence is higher in younger patients
Recurrent disease associated with high mortality
1/4 of patients remain symptomatic after surgery
