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Year 3 > Diverticular disease (GI) > Flashcards

Diverticular disease (GI) Flashcards

1
Q

Define diverticular disease.

A

Any clinical state caused by symptoms pertaining to colonic diverticula, and includes a wide-ranging spectrum from asymptomatic to severe and complicated disease

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2
Q

Define colonic diverticulitis.

A

Herniation of the mucosa and submucosa through the muscular layer of the colonic wall and may be the result of smooth muscle overactivity

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3
Q

Which parts of the colon is diverticular disease more likely to be found in? (2)

A
  • sigmoid colon
  • descending colon
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4
Q

Which specific site is diverticular disease found at?

A

Between taenia coli where vessels pierce muscle to supply mucosa

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5
Q

Why is the rectum spared in diverticular disease?

A

Does not contain taenia coli (diverticular disease occurs between taenia coli)

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6
Q

What diseases make up diverticular disease? (4)

A
  • 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
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7
Q

What is Saint’s triad of disorders?

A
  • hiatus hernia
  • colonic diverticulitis
  • gallstones
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8
Q

What causes segmentation of colonic wall in diverticulosis?

A

Nitric oxide

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9
Q

How can diverticular disease often present?

A

Asymptomatic + found incidentally

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10
Q

What are the clinical features of diverticular disease? (6)

A
  • LLQ abdominal pain (severe)
  • leukocytosis
  • fever
  • change in bowel habit - constipation>diarrhoea
  • rectal bleeding
  • nausea and vomiting
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11
Q

What are the signs of acute diverticulitis? (3)

A
  • leukocytosis
  • fever
  • guarding and tenderness in LLQ (acute sharp LIF pain)
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12
Q

What are the signs of peritonitis? (3)

A
  • diffuse abdominal tenderness
  • guarding
  • signs of infection
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13
Q

What could a palpable abdominal mass be in diverticular disease?

A

Abscess

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14
Q

What types of fistula can be seen in diverticular disease? (2)

A
  • colovesical fistula - passing brown urine (faecaluria) or air/gas in urine (pneumaturia) + recurrent UTIs
  • colovaginal fistula - faecal matter/flatus in vaginal discharge
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15
Q

What are some risk factors of diverticular disease? (9)

A
  • 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
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16
Q

What are the 1st-line investigations for diverticular disease? (3)

A
  • FBC with differential - polymorphonuclear leukocytosis
  • U&Es - to assess kidney function and determine if contrast CT can be done
  • CRP - high
17
Q

When patients with diverticular disease present to clinic, which 1 of 3 investigations is usually done?

A
  • colonoscopy - to visualise
  • CT cologram
  • barium enema - saw-tooth appearance of lumen
18
Q

What is the optimum imaging modality for diverticular disease?

A

CT

19
Q

What scan is done to detect inflammation in diverticular disease, and what do we see?

A
  • 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
20
Q

How can we identify perforation in diverticular disease? (1 + 2)

A

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
21
Q

What would FBC show in diverticulitis? (3)

A
  • high WCC
  • high CRP
  • polymorphonuclear leukocytosis
22
Q

How is the severity of diverticular disease classified?

A

Hinchey classification:
I. para-colonic abscess (confined)
II. pelvic abscess (distant)
III. purulent peritonitis (generalised)
IV. faecal peritonitis

23
Q

What are some differential diagnoses for diverticular disease? (9)

A
  • endometriosis
  • colorectal cancer
  • appendicitis
  • ulcerative colitis
  • Crohn’s disease
  • UTI
  • pyelonephritis
  • ischaemic colitis (generalised atherosclerosis + abdo pain + rectal bleeding)
  • PID
24
Q

What is the 1st-line management for asymptomatic diverticulosis?

A

Dietary and lifestyle modifications i.e. increase dietary fibre and fluids

25
Q

What is the 1st-line management for symptomatic diverticular disease?

A
  • dietary and lifestyle modifications i.e. increase dietary fibre and fluids
  • consider analgesia (paracetamol not NSAIDs/opioids)
  • consider antispasmodic for abdominal cramping (dicycloverine)
26
Q

What is the 1st-line management for acute diverticulitis (uncomplicated)?

A
  • analgesia (paracetamol)
  • oral Abx (amoxicillin/clavulanate)
  • if not resolved in 72h, admit for IV Abx (ceftriaxone + metronidazole)
  • consider antispasmodic (dicycloverine)
  • low-residue diet
27
Q

What is the 1st-line management for acute diverticulitis (complicated)?

A
  • 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
28
Q

When might surgery be necessary for diverticular disease?

A
  • 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)
29
Q

What are some complications of diverticular disease? (7)

A
  • abscess
  • perforation
  • fistula
  • obstruction (due to strictures)
  • colorectal neoplasm
  • haemorrhage
  • diverticulitis
30
Q

How can we assess for complications of diverticular disease?

A

CT abdomen

31
Q

How do we manage abscess from diverticular disease?

A

Bowel rest + broad spectrum Abx + CT guided percutaneous drainage

32
Q

How do we manage perforation from diverticular disease?

A

Urgent laparotomy (Hartmann’s procedure if severe, laparoscopic drainage if mild) + Abx + IV fluids + bowel rest

33
Q

Describe the prognosis of diverticular disease.

A
  • most patients do not need surgery
  • recurs in 1/3 patients
  • after surgery 1/4 patients remain symptomatic

Year 3 (80 decks)

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