Diverticular disease (GI) Flashcards
Define diverticular disease.
Any clinical state caused by symptoms pertaining to colonic diverticula, and includes a wide-ranging spectrum from asymptomatic to severe and complicated disease
Define colonic diverticulitis.
Herniation of the mucosa and submucosa through the muscular layer of the colonic wall and may be the result of smooth muscle overactivity
Which parts of the colon is diverticular disease more likely to be found in? (2)
- sigmoid colon
- descending colon
Which specific site is diverticular disease found at?
Between taenia coli where vessels pierce muscle to supply mucosa
Why is the rectum spared in diverticular disease?
Does not contain taenia coli (diverticular disease occurs between taenia coli)
What diseases make up diverticular disease? (4)
- diverticulosis - presence of diverticula without symptoms (not treated); may have blood in stool and can lead to diverticulitis
- diverticular disease - symptomatic diverticulosis (mild abdominal pain and no systemic symptoms) associated with complications (haemorrhage, infection)
- diverticulitis - inflammation of a diverticulum/diverticula (systemic symptoms e.g. fever, malaise; no symptoms of acute abdomen)
- diverticular bleed - diverticulum erodes into a vessel –> painless bleed
What is Saint’s triad of disorders?
- hiatus hernia
- colonic diverticulitis
- gallstones
What causes segmentation of colonic wall in diverticulosis?
Nitric oxide
How can diverticular disease often present?
Asymptomatic + found incidentally
What are the clinical features of diverticular disease? (6)
- LLQ abdominal pain (severe)
- leukocytosis
- fever
- change in bowel habit - constipation>diarrhoea
- rectal bleeding
- nausea and vomiting
What are the signs of acute diverticulitis? (3)
- leukocytosis
- fever
- guarding and tenderness in LLQ (acute sharp LIF pain)
What are the signs of peritonitis? (3)
- diffuse abdominal tenderness
- guarding
- signs of infection
What could a palpable abdominal mass be in diverticular disease?
Abscess
What types of fistula can be seen in diverticular disease? (2)
- colovesical fistula - passing brown urine (faecaluria) or air/gas in urine (pneumaturia) + recurrent UTIs
- colovaginal fistula - faecal matter/flatus in vaginal discharge
What are some risk factors of diverticular disease? (9)
- age>50 (decreased mechanical strength of colon walls)
- constipation
- diet: low fibre, high salt/meat/sugar
- NSAIDs + opioids
- steroids
- obesity
- decreased physical activity
- smoking
- excessive alcohol and caffeine
What are the 1st-line investigations for diverticular disease? (3)
- FBC with differential - polymorphonuclear leukocytosis
- U&Es - to assess kidney function and determine if contrast CT can be done
- CRP - high
When patients with diverticular disease present to clinic, which 1 of 3 investigations is usually done?
- colonoscopy - to visualise
- CT cologram
- barium enema - saw-tooth appearance of lumen
What is the optimum imaging modality for diverticular disease?
CT
What scan is done to detect inflammation in diverticular disease, and what do we see?
- contrast CT of abdomen for patients with suspected acute diverticulitis and raised inflammatory markers
- mural thickening of the colon, presence of pericolic fat stranding in sigmoid colon, mass, abscess
- gas in bladder if fistula
How can we identify perforation in diverticular disease? (1 + 2)
Erect CXR and plain abdominal films
- pneumoperitoneum - presence of air in abdominal cavity
- Rigler’s sign - sign of pneumoperitoneum when gas is outlining both sides of bowel wall
What would FBC show in diverticulitis? (3)
- high WCC
- high CRP
- polymorphonuclear leukocytosis
How is the severity of diverticular disease classified?
Hinchey classification:
I. para-colonic abscess (confined)
II. pelvic abscess (distant)
III. purulent peritonitis (generalised)
IV. faecal peritonitis
What are some differential diagnoses for diverticular disease? (9)
- endometriosis
- colorectal cancer
- appendicitis
- ulcerative colitis
- Crohn’s disease
- UTI
- pyelonephritis
- ischaemic colitis (generalised atherosclerosis + abdo pain + rectal bleeding)
- PID
What is the 1st-line management for asymptomatic diverticulosis?
Dietary and lifestyle modifications i.e. increase dietary fibre and fluids
What is the 1st-line management for symptomatic diverticular disease?
- dietary and lifestyle modifications i.e. increase dietary fibre and fluids
- consider analgesia (paracetamol not NSAIDs/opioids)
- consider antispasmodic for abdominal cramping (dicycloverine)
What is the 1st-line management for acute diverticulitis (uncomplicated)?
- analgesia (paracetamol)
- oral Abx (amoxicillin/clavulanate)
- if not resolved in 72h, admit for IV Abx (ceftriaxone + metronidazole)
- consider antispasmodic (dicycloverine)
- low-residue diet
What is the 1st-line management for acute diverticulitis (complicated)?
- if unstable - resuscitation
- if stable with major bleed - colonoscopy to identify and treat lesion, surgery if bleeding continues + fluids + IV Abx
- if abscess/perforation/fistulae/obstruction - radiological drainage/surgery
When might surgery be necessary for diverticular disease?
- in patient with recurrent diverticulitis attacks or complications (abscess, perforation, fistulae, obstruction)
- Hartmann’s procedure - resection of rectosigmoid colon and end colostomy performed
- (less severe perforation –> laparoscopic washout and drain)
What are some complications of diverticular disease? (7)
- abscess
- perforation
- fistula
- obstruction (due to strictures)
- colorectal neoplasm
- haemorrhage
- diverticulitis
How can we assess for complications of diverticular disease?
CT abdomen
How do we manage abscess from diverticular disease?
Bowel rest + broad spectrum Abx + CT guided percutaneous drainage
How do we manage perforation from diverticular disease?
Urgent laparotomy (Hartmann’s procedure if severe, laparoscopic drainage if mild) + Abx + IV fluids + bowel rest
Describe the prognosis of diverticular disease.
- most patients do not need surgery
- recurs in 1/3 patients
- after surgery 1/4 patients remain symptomatic
