Diverticulitis Flashcards
What is diverticula formation ass with?
Low fibre diet
Lowers stool bulk, slows transit time and increases luminal pressure
Diverticulosis vs diverticular disease vs diverticulitis
Diverticulosis = asymptomatic
Diverticular disease = intermittent lower abdo pain without inflammation and infection
Diverticulitis = Diverticula inflamed from infection
Potential features of complicated diverticulitis
Ass with abscesses, peritonitis, fistual, obstruction, perforation
Risk factors diverticular disease
Older - over 50-60
Genetic
Low fibre diet
Red meat consumption
Smoking Obesity
NSAIDs + opioids
Immunosupression
Prev surgical prodcedures or colon evaluations
Comorbidities
Why might people with diverticular need an emergency trasnfusion?
Diverticular haemorrhage can occur - penetrating blood vessels responsible for bowel wall weakness vulnerable to injury
1/3 are meassive and require resus
Bleeding resolves spontaneously in majority of cases
Life threatening complications of diverticulitis
Intra abdominal abscess formation - pericolic, pelvic abscess
Perforation + peritonitis
Stricutre and fistual formation
Intestinal obstruction - fibrosis and stricture from inflammation
Sepsis
Signs of stricutre and fistula formation
Faecaluria, pneumaturia, pyuria, faeces through vagina - fistulas bladder, vagina, uterus, skin, other part of bowel
Signs of intestinal obstruciton
Colicky abdo pain
Absolute constipation - no flatus or stool
Vomitting
Abdo distension
Signs of diverticular disease
Intermittent abdo pain LLQ, tender OE
Bloat, constipation, diarrhoea, nausea
Rectal bleeding
Fever
Dysuria
When suspect diverticulitis
Constant abdo pain, severe start in hypogastrium -> LLQ
Fever
Sudden change in bowel habit + significant recta, bleeding or mucus
Tenderness in LLQ, palpable mass, history of diverticular disease
When is pain releived and triggered in diverticular disease?
Triggered by eating, relieved by passing stool or flatus
Other exams to consider apart from GI
Pelvic - gynae cause
PR exam = pelvic tenderness
Investigations diverticulitis imaging
Endoscopy
Colonoscopy
CT colonography
INvestigations general diverticulitis
FBC
Faecal occult blood test
U+Es
eGFR
Urinalysis
CRP
Important GI differential diagnosis
COLORECTAL CNACER
Bowel obstruction
Ischaemic colitis
Appendicitis
IBD
Gastroenteritis
IBS
GYNAE differential diagnosis
PID
Ovarian torsion
Extopic preganancy
Endometriosis
When arrange same day hospital admission for someone with acute diverticulitiis
Uncontrollable abdo pain and any features of complications
Dehydrated or at risk of
Unable to take or tolerate oral antibiotics
Over 65 years
Significant comorbiditity or immunosupression
What is 1st line treatment for systemically unwell with acute diverticulitis but no complciations
Co-amoxiclav 500/125 mg 3 times daily for 5 days
Alternatives if allergic to penicillin 1st line treatment acute diverticulitis
If allergic to penicillin -
cefalexin 500mg 2-3 x /day for 5 days + Metronidazole - 400mg 3x daily for 5 days
OR
trimethoprim (200 mg 2x/day for 5 days) + metronidazole (400 mg 3x/day for 5 days).
If patient is systemically well with acute diverticulitis how manage
Simple analgesia eg paracetemol but AVOID NSAIDs + opioids
No antibiotic therapy
Safety net - come back if worsen or persist
Why shouldnt take NSAIDs or opioids with diverticulitis
Causes constipation -> Increased risk diverticular perforation
Information to provide for acute diverticulitis
Diet and lifestyle advice
The course of acute diverticulitis and likelihood of complications or recurrent episodes
Symptoms
Whne and how to seek further medical advice
Possible investigations and treatments
Risks of interventions and treatments eg antibiotic resistance, how invasive these are
Role of surgery and outcomes
Specialist investigations
CT scan abdo and pelvis
MRI scan
US abdo and pelvis
Urgent colonoscopy or CT colonography
Specialist management for acute diverticulitis
IV antibiotics, fluid replacement, analgesia
Urgent surgery if complicated
-Percutaneous drainage of abscess
Laprascopic lavage
Simple colostomy formation
Signmoid resection with colostomy
Sigmoid resection - primary
Elective surgery for recurrence
Management of diverticular disease
Admit if significatn rectal bleeding and haemodynamically unstable
Advise:
No NSAIDs or opioids
Weight loss, exercise, hydration, high fibre diet
ulk forming laxatives if high fibre diet unacceptable
Simple ana;gesia
Antispasmodic - mebeverine
Antispasmodic example
Mebeverine
Score for diverticulitis
Hinchey classification
Hinchey classification stages
stage 0:
clinical: mild clinical diverticulitis
CT finding: diverticula with colonic wall thickening
stage Ia:
clinical: confined pericolic inflammation or phlegmon
CT finding: pericolic soft tissue changes
stage Ib:
clinical: pericolic or mesocolic abscess
CT finding: Ia changes and pericolic or mesocolic abscess
stage II:
clinical: pelvic, distant intra-abdominal or retroperitoneal abscess
CT finding: Ia changes and distant abscess, usually deep pelvic
stage III:
clinical: generalized purulent peritonitis
CT finding: localized or generalized ascites, pneumoperitoneum, peritoneal thickening
stage IV:
clinical: generalized fecal peritonitis
CT finding: same as stage III
Clinical use of Hinchey classifciation
abscesses in stage Ib and II drained by interventional radiology
stage III and IV disease is managed with emergent surgery.
