Diverticular disease of the colon

Question 1

What is the definition of a diverticulum?

Answer 1

Sac-like protrusion of the colonic wall

Question 2

Definition of diverticulosis

Answer 2

Describes the presence of diverticula

Question 3

Definition of diverticulitis

Answer 3

inflammation of the diverticula

Question 4

What are the two types of diverticulae

Answer 4

• True diverticulae: sac-like protrusions consisting of all the layers of the colonic wall
• False or pseudo-diverticulae: sac like protrusions consisting of mucosa and submucosa only

Question 5

What does diverticular disease of the colon refer to

Answer 5

pseudo diverticulae

Question 6

Where do diverticulae usually occur

Answer 6

Four well defined weak points in the bowel wall where the blood vessels penetrate the muscle layer. They occur on either side of the mesenteric taenia and on the mesenteric side of the anti-mesenteric taenia.
Rare below the recto sigmoid junction and they can occur in the appendix but are rare.

Question 7

What is an important predisposing factor for diverticular disease

Answer 7

Low fibre diet

Question 8

Four ways in which diverticular disease can present

Answer 8

• Asymptomatic
• Symptomatic
• Diverticular bleed
• Diverticulitis and its complications

Question 9

How does symptomatic diverticulosis present

Answer 9

• Attacks of left iliac fossa pain, which is at time colicky in nature
• Bloating
• Flatulence
• Altered bowel habit
• Symptoms disapear after defaecation or passage of flatulence
• Tenderness in left iliac fossa with no clinical or laboratory signs of inflammation

Question 10

Treatment of diverticulosis

Answer 10

Surgery is rarely indicated and a high fiber diet is recommended

Question 11

How does diverticulitis usually develop

Answer 11

Obstruction of a diverticulum (by a faecolith) –> increased intraluminal pressure, inflammation and perforation

Question 12

In diverticulitis, abscesses can involve adjacent structures, resulting in fistulae, which are the most common fistulae?

Answer 12

Colovesical

Question 13

What condition is usually misdiagnosed as diverticultis

Answer 13

Irritable bowel syndrome

Question 14

How does diverticulitis usually present

Answer 14

• Left iliac fossa pain
• Fever
• Pain
• Bloating and leucocytosis
• Alteration of bowel habit
• Urinary symptoms may occur
• Rectal bleeding is rare
• Diverticulitis of isolated diverticulum of the caecum may be indistinguishable from appendicitis

Question 15

best investigation in suspected diverticulitis

Answer 15

CT scan
Colonoscopy may be useful if a co-existent malignancy is suspected. All patients should have a diagnostic colonoscopy some time after the acute episode has settled

Question 16

What is uncomplicated diverticulitis

Answer 16

Occurs when an inflamed or perforated diverticulum is walled off by the omentum or adjacent structures resulting in localised inflammation

Question 17

Acute management of uncomplicated diverticulitis

Answer 17

Most patients require hospitalisation and should be placed on antibiotics such as ciprofloxin and metronidazole to cover gram negative bacilli and anaerobes. antibiotics can be administered orally when tolerated, and continued for 7-10 days

Question 18

What is usually the outcome of conservative management of first attack of diverticulitis

Answer 18

• One third: asymptomatic
• One third: episodic cramps
• One third: suffer second episode

Question 19

When does complicated diverticulitis occur

Answer 19

• The perforation leads to formation of a localised abscess
• Fistula formation to adjacent organs, usually the bladder
• Uncontained perforation leading to generalized peritonitis
• Colonic stricture causing bowel obstruction

Question 20

Hinchey classification of diverticulitis

Answer 20

• Stage 1: pericolic or mesenteric abscess
• Stage 2: walled off pelvic abscess
• Stage 3: generalised purulent peritonitis
• Stage 4: Generalised faeculent peritonitis

Question 21

How should an abscess be treated in diverticulitis

Answer 21

• Drained percutaneously
• If inaccessible: laparotomy and open drainage may be necessary
• Laparoscopic lavage and abscess drainage in the acute setting has become more popular
• Presence of frank faecal material is an indication to convert to open surgery
• May need resection 6 weeks after drainage

Question 22

How does a colovesical fistulae present

Answer 22

• Pyuria
• Faecaluria
• Pneumaturia
• Recurrent urinary tract infections

Question 23

What is a differential diagnosis in colovesical fistula

Answer 23

-Carcinoma of the colon

Question 24

What is the management of a colovesical fistulae

Answer 24

• Fistula excised along with diseased segment of colon and primary anastamosis is usually appropriate
• Large bladder opening: suture closure
• Small opening: left alone and bladder catheter left in situ for about 10 days or until cystogram demonstrates absence of leak
• Omentum should be interposed between the colon and bladder at the time of surgery

Question 25

Two causes of generalised peritonitis in diverticulitis

Answer 25

• Abscess that is initially localized, expands and perforates (purulent peritonitis)
• Diverticulum perforates and is not sealed by the body’s natural defences (faeculent peritonitis)

Question 26

Management of colonic perforation

Answer 26

• IV fluid resuscitation
• Analgesia
• Antibiotics
• Generalized peritonitis: urgent laparotomy or laparoscopy is required
• Hartmann’s procedure is the safest operation, if surgeon is experienced- resection and primary anastomosis may be done in selected patients

Question 27

two circumstances in which colonic obstruction occurs and treatment in each case

Answer 27

• Small bowel adheres to the infectious process; managed with nasogastric drainage, antibiotics and percutaneous drainage of any abscesses
• Narrowing of sigmoid colon: muscular hypertrophy of the bowel wall or fibrotic stricture. Rarely cause problems unless sigmoid stricture in an area containing numerous diverticulae

Question 28

How does a diverticular bleed present

Answer 28

• Brisk rectal bleeding
• Abrupt and painless
• Mild lower abdominal cramps and rectal urgency followed by the passage of red blood/ clots

Question 29

In how many percentage of patients is diverticular bleeding from the right colon (proximal to the splenic flexure)

Answer 29

50%

Question 30

Best method of diagnosis and treatment of diverticular bleeding

Answer 30

Colonoscopy after rapid bowel preparation

Question 31

options for endoscopic control of a bleeding blood vessel

Answer 31

• Adrenaline injection

- heater probe

Question 32

If a bleeding site is not found, what surgical procedure should be done

Answer 32

Subtotal colectomy with ileorectal anastomosis