Diverticular Disease - Acute Diverticulitis

Question 1

Define Diverticula

Answer 1

!Acquired sac-like herniation of the mucosa through the colonic wall

Question 2

Define Diverticulosis

Answer 2

Presence of diverticula without inflammation!

Question 3

Define Diverticular Disease
Give 3 specific symptoms

Answer 3

Symptomatic Diverticulosis => Presence of diverticula with symptoms AKA painful Diverticulitis
Altered bowel habit of Diarrhoea and constipation (mostly) => !Pellet Like Stool!
LIF pain/discomfort
Bloating
Perforation => sepsis
Recurrent UTI (colovesical fistula)

Question 4

Where does the herniation typically occur?
What are the most common locations for Diverticulosis? State them in descending order of prevalence.

Answer 4

Herniation typically occurs between tenia coli as it is the entry point of nutrient arterioles (puncture through wall) => Weakest point
Sigmoid colon (most common)
Sigmoid colon + Descending colon
Sigmoid + Descending + Transverse
Pancolic
Cecal

Question 5

What is meant by true and false diverticula?

Answer 5

Colonic diverticula are typically acquired and involve no muscle layers within the wall of the colon => False
Congenital diverticula typically involve all 3 muscle layers => true
Similar to true and false aneurysm

Question 6

Give 6 RF for Diverticular disease. total = 9

Answer 6

Age (50% over 50)
Low fibre diet
Constipation a/w straining
Obesity
Physical inactivity
Smoking
Connective tissue disease: Ehler Danlos, Marfan’s (makes walls weaker as in AAA)
AD polycystic kidney disease (Risk factor for bleeding as well in stroke and SAH)

Question 7

What is the pathogenesis of Diverticular disease from low fibre diet?

Answer 7

Low fibre diet => less stool volume => increased intraluminal pressure (think vasoconstriction) => muscle hypertrophy => herniation

Question 8

What is the most common presentation of a patient with diverticulosis?

Answer 8

Diverticulosis = presence of diverticula without inflammation
The vast majority of patients are found incidentally during colonoscopy or barium enema => asymptomatic

Question 9

What is the typical clinical presentation of simple acute diverticulitis?

Answer 9

1) Sx of acute abdomen (Sudden abdominal pain, nausea, vomiting, altered bowel habits, tenesmus, inability to empty bowels, fever/chills, bloating/swelling and tenderness/guarding, rebound guarding, tachycardia, tachypnea
2) LIF tenderness (rarely RIF)
3) Alternating/altered bowel habit: Constipation (mostly) and Diarrhoea with !Pellet-like stool!
4) Painless Spontaneous bleeding => Hematochezia

Question 10

State the complications of Acute Diverticulitis or Diverticular disease as a whole

Answer 10

Obstruction/stricture formation
Abscess formation
Perforation/Peritonitis
Diverticular Fistula

Question 11

A patient presents with simple acute diverticulitis with painless spontaneous bleeding. What is the significance of quantifying the volume?

Answer 11

Small volume = normal erosion of mural vessels by diverticulitis
Large volume = Rupture of a peri diverticular vessel

Question 12

What is Rebound Tenderness a sign of?

Answer 12

Inflammation or irritation of the peritoneum => Peritonitis

Question 13

What are the immediate investigations you will conduct in the setting of acute diverticulitis? (rationale where applicable)

Answer 13

Bloods: FBC (High WCC, majority neutrophils!!), U&E (disturbances), CRP, Coag, blood cultures (if systemically unwell), amylase

Imaging: !Erect CXR!
PFA for obstruction
CT angio/IV contrast CT abdomen to look for complications

LATER: Colonoscopy 6-8 weeks later to look for complications and malignancy

Question 14

Although the vast majority of diverticula are found incidentally on colonoscopy or barium enema, why aren’t colonoscopies EVER done in the setting of acute diverticulitis?

Answer 14

To prevent causing bleeding and perforation. Instead we would schedule an colonoscopy 6-8 weeks later to look for possible complications and malignancies

Question 15

What antibiotics would you prescribe to a patient with Acute diverticulitis?

Answer 15

IV Co-amox/Cefuroxime + Metronidazole

Question 16

What is your management plan for a patient presenting to the hospital for a colonoscopy with an incidental finding of diverticula?

Answer 16

I will advise them to go for a fibre-rich diet, weight loss, stop smoking, increased exercise
I will prescribe probiotics and stool softeners

Question 17

What is your full management of simple acute diverticulitis where a 45 year old patient is somewhat well with LIF tenderness, no rebound tenderness, and no bleeding PA. Include your conservative, medical, and surgical management (include indications). Im not asking for ABCDE management although you do it if needed obviously

Answer 17

Conservative: High fiber diet, Probiotics, Stool softener (+reduce RFs)

Medical: IV antibiotics Coamox/pip taz + Gent/Metronidazole

Surgical: US/CT guided Abscess drainage if presence of abscess >3cm
Laparoscopy +/- Washout escalated to Hartmann’s Procedure
Indications:Main -> not resolved on antibiotics, complications of diverticulitis in an uncomplicated presentation => peritonitis (Hinchey Classification III,IV), fistula, undrainable abscess.

Extra points! I will schedule a colonoscopy in 6-8 weeks to look for complications and malignancy as I would not want to risk perforation or bleeding in acute diverticulitis.

Question 18

What is Hartmann’s procedure?

Answer 18

Proctosigmoidectomy, resecting the diseased segment (sigmoid), leaving the patient with a left-sided stoma

Question 19

In acute diverticulitis how does obstruction occur as a complication?
How would you treat obstruction?

Answer 19

Stricture formation from chronic inflammation => luminal narrowing
Stricture tx: Endoscopic dilatation

Question 20

In acute diverticulitis how do abscesses occur as a complication?
What are the types (locations) of abscesses seen in acute diverticulitis?
How would a patient present with an abscess?
What are your options for treating the abscess?
How would you treat a Perforated abscess?

Answer 20

Pathogenesis: Persistant inflammation + microperforations from microorganisms => pericolic abscess and may extend into paracolic space => paracolic abscess which may then extend to distant parts such as Pelvic and Retroperitoneal abscesses (these are the types)

Presentation: (very vague so no need for all) unresolving LIF pain + systemically unwell + features of sepsis + nausea vomiting.

Tx:
<3cm => conservative management => IV antibiotics of coamox + metronidazole
>3cm => US/CT guided drainage If undrainable => Laparoscopic washout +/- Laparotomy

Perforated abscess = Purulent Peritonitis => Laparoscopic washout +/- Laparotomy

Question 21

How would you approach a patient presenting with acute diverticulitis WITH bleeding?

Answer 21

In all cases ABCDE, Hx and exam to determine if patient is stable or unstable
Stable => continue supportive care => fluids, group and hold, correct coag etc..
Unstable => Group and cross-match, CT angiography with vasopressin injection and transcatheter embolization

Question 22

In acute diverticulitis, what are the two types of peritonitis?
Which is worse?
How would you treat each type?

Answer 22

Purulent Peritonitis due to perforation of an abscess (Hinchey III)
Tx: Laparoscopy and Washout +/- Laparotomy

Faeculent Peritonitis due to perforation of diverticular segment (Hinchey IV)
Tx: Hartmann’s procedure

Question 23

A patient presents with the symptoms of acute diverticulitis but with pain on the right side. You suspect it might be appendicitis but your consultant shows you the pain is not severe enough and is not maximal on McBurney’s point. What is the explanation to this?

Answer 23

Cecal variant (5%) of diverticular disease. rare but exists

Question 24

A patient presenting to the ED complaining of nausea, LIF pain, constipation, pebble-like stool and recurrent UTIs. What is your running diagnosis?

Answer 24

Acute Diverticulitis complicated by colovesical fistula

Question 25

Fistula formation is one of the 4 major complications of diverticular disease. What are the 2 most common fistulas formed here?
How would you treat them?

Answer 25

Colovesical
Colovaginal

Tx: Resection of effected segment

Question 26

What additional symptoms would be present in a patient diagnosed with acute diverticulitis complicated with colovesical fistula?

Answer 26

Recurrent UTIs
Pneumaturia (gas and bubbles in urine)
Debris in urine

Question 27

Many patients with acute diverticulitis have longstanding chronic diverticulitis. 30% of patients will haver further attacks after their first presentation and 50% after their second. What is the definitive treatment for these patients suffering from chronic diverticulitis?
What are the indications for this treatment? (4)

Answer 27

Tx: Colectomy (could be progressed to colostomy (left sided stoma))
Indications:
1) >2 acute attacks successfully treated
2) 1 attack requiring hospitalization in patient <40
3) 1 complicated attack
4) 1 attack in an immunocompromised patient

Question 28

What classification is used in acute diverticulitis? (List criteria)
List the management for each

Answer 28

Hinchey Classification
I - Pericolic or paracolic abscess
II - Distant abscess (retroperitoneal, pelvic)
III - Purulent Peritonitis
IV - Faeculent Peritonitis