Diverticulitis

Question 1

What is diverticula formation ass with?

Answer 1

Low fibre diet
Lowers stool bulk, slows transit time and increases luminal pressure

Question 2

Diverticulosis vs diverticular disease vs diverticulitis

Answer 2

Diverticulosis = asymptomatic
Diverticular disease = intermittent lower abdo pain without inflammation and infection
Diverticulitis = Diverticula inflamed from infection

Question 3

Potential features of complicated diverticulitis

Answer 3

Ass with abscesses, peritonitis, fistual, obstruction, perforation

Question 4

Risk factors diverticular disease

Answer 4

Older - over 50-60
Genetic
Low fibre diet
Red meat consumption
Smoking Obesity
NSAIDs + opioids
Immunosupression
Prev surgical prodcedures or colon evaluations
Comorbidities

Question 5

Why might people with diverticular need an emergency trasnfusion?

Answer 5

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

Question 6

Life threatening complications of diverticulitis

Answer 6

Intra abdominal abscess formation - pericolic, pelvic abscess
Perforation + peritonitis
Stricutre and fistual formation
Intestinal obstruction - fibrosis and stricture from inflammation
Sepsis

Question 7

Signs of stricutre and fistula formation

Answer 7

Faecaluria, pneumaturia, pyuria, faeces through vagina - fistulas bladder, vagina, uterus, skin, other part of bowel

Question 8

Signs of intestinal obstruciton

Answer 8

Colicky abdo pain
Absolute constipation - no flatus or stool
Vomitting
Abdo distension

Question 9

Signs of diverticular disease

Answer 9

Intermittent abdo pain LLQ, tender OE
Bloat, constipation, diarrhoea, nausea
Rectal bleeding
Fever
Dysuria

Question 10

When suspect diverticulitis

Answer 10

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

Question 11

When is pain releived and triggered in diverticular disease?

Answer 11

Triggered by eating, relieved by passing stool or flatus

Question 12

Other exams to consider apart from GI

Answer 12

Pelvic - gynae cause
PR exam = pelvic tenderness

Question 13

Investigations diverticulitis imaging

Answer 13

Endoscopy
Colonoscopy
CT colonography

Question 14

INvestigations general diverticulitis

Answer 14

FBC
Faecal occult blood test
U+Es
eGFR
Urinalysis
CRP

Question 15

Important GI differential diagnosis

Answer 15

COLORECTAL CNACER
Bowel obstruction
Ischaemic colitis
Appendicitis
IBD
Gastroenteritis
IBS

Question 16

GYNAE differential diagnosis

Answer 16

PID
Ovarian torsion
Extopic preganancy
Endometriosis

Question 17

When arrange same day hospital admission for someone with acute diverticulitiis

Answer 17

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

Question 18

What is 1st line treatment for systemically unwell with acute diverticulitis but no complciations

Answer 18

Co-amoxiclav 500/125 mg 3 times daily for 5 days

Question 19

Alternatives if allergic to penicillin 1st line treatment acute diverticulitis

Answer 19

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).

Question 20

If patient is systemically well with acute diverticulitis how manage

Answer 20

Simple analgesia eg paracetemol but AVOID NSAIDs + opioids
No antibiotic therapy
Safety net - come back if worsen or persist

Question 21

Why shouldnt take NSAIDs or opioids with diverticulitis

Answer 21

Causes constipation -> Increased risk diverticular perforation

Question 22

Information to provide for acute diverticulitis

Answer 22

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

Question 23

Specialist investigations

Answer 23

CT scan abdo and pelvis
MRI scan
US abdo and pelvis
Urgent colonoscopy or CT colonography

Question 24

Specialist management for acute diverticulitis

Answer 24

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

Question 25

Management of diverticular disease

Answer 25

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

Question 26

Antispasmodic example

Answer 26

Mebeverine

Question 27

Score for diverticulitis

Answer 27

Hinchey classification

Question 28

Hinchey classification stages

Answer 28

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

Question 29

Clinical use of Hinchey classifciation

Answer 29

abscesses in stage Ib and II drained by interventional radiology stage III and IV disease is managed with emergent surgery.