DIVERTICULITIS Flashcards
Diverticulum:
abnormal sac-like protrusion from the wall of a
hollow organ
Diverticulosis
presence of multiple diverticula
Diverticulitis
inflammation of diverticula
True (congenital) diverticuli:
contain all layers of colonic wall,
often right-sided
False (acquired) diverticuli:
contain mucosa and submucosa,
often left-sided
Colonic diverticula
protrusions of mucosa through the muscular
layer of the intestine. Because these mucosal herniations are
devoid of the normal muscular layers, they are pseudodiverticula
Diverticulosis
is the presence of multiple diverticula in the colon, resulting from long time consumption of low fiber diet. There is an increase in the intrabowel
pressure due to straining, constipation (which may be a result of low fiber diet) which causes mucosal outpouchings on the wall of the intestine
Epidemiology
5-50% of Western population,
o Lower incidence in non-Western countries. Rare in sub saharan African Blacks who consume a high
fiber diet
o M=F
o Prevalence is age dependent:
o 95% involve sigmoid colon (site of highest pressure)
o It is an acquired condition
Pathogenesis
high intraluminal pressures cause outpouching to occur at point of greatest weakness, most
commonly where vasa recta penetrate the circular muscle layer, therefore increased risk of hemorrhage.
Diverticula are herniations of mucosa at sites of penetration of the muscular wall by arterioles, on the
mesenteric side of the anti mesenteric taenia. When there is a large volume of fiber the contractile pressure
required to propel the feces forward is low. Instead, decreased amount of fibers in the colon causes
increased colonic pressures which are responsible for the herniations.
Where?
Sigmoid: 50% of patients with diverticulosis (it is the most frequent site of diverticulitis, too) à
SIGMOID DIVERTICULITIS NEEDS TO BE DISTINGUISHED FROM CANCER
o Descending colon: 40%
o Entire colon: 5 – 10%
o There is often hypertrophy of the muscular layers of the colonic wall associated with
diverticulosis.
RFs
lifestyle: low-fibre diet (predispose to motility abnormalities and higher intraluminal pressure),
inactivity, obesity. Decreased consumption of unprocessed cereals and increased consumption
of sugar and meat.
o muscle wall weakness from aging and illness (e.g. Ehler-Danlos, Marfan’s)
CLINICS
Uncomplicated diverticulosis: asymptomatic (70-80%)
o Episodic abdominal pain (often LLQ), bloating, flatulence, constipation, diarrhea
o Absence of fever/leukocytosis
o No physical exam findings or poorly localized LLQ tenderness
o Complications
§ diverticulitis (15-25%): 25% of which are complicated (i.e. abscess, obstruction, perforation, fistula)
§ bleeding (5-15%): PAINLESS rectal bleeding, 30-50% of massive lower GI bleeding.
§ diverticular colitis (rare): diarrhea, hematochezia, tenesmus, abdominal pain
§ Diverticular disease-associated colitis (DAC)- mucosal inflammation in a colon segment affected with DD with relative sparing of the
rectum and proximal colon.
TREATMENT
Uncomplicated diverticulosis: high fibre, education
o Diverticular bleed
§ initially workup and treat as any LGIB
§ if hemorrhage does not stop, resect involved region
DIVERTICULITIS
it is a condition brought on by infection or perforation of diverticula, which are bulges forming in the lower part of the large intestine or colon.
Where?
The sigmoid colon has this highest incidence of diverticula and it is the most frequent site for
involvement with diverticulitis.
EPIDEMIOLOGY
95% left-sided in patients of Western countries,
o 75% right-sided in Asian populations
PATHOGENESIS
Erosion of the diverticular wall by increased intraluminal pressure or inspissated food particles à
inflammation and focal necrosis à micro or macroscopic perforation à pericolonic inflammation
o Usually the inflammation is mild as the perforation is walled off by pericolic fat and mesentery;
o Possible complications include abscess, fistula (e.g. pneumaturia or fecaluria)12, or obstruction
(most often is insidious, but patients can occasionally have significant obstructive symptoms- usually
due to a phlegmon or abscess adhering to the small bowel)
Diverticulitis has a broad spectrum of severity (single episode, repeated episodes or fulminant
complicated disease characterized by life-threatening sepsis).
HINCHLEY
It is a classification regarding the abscesses formed from the
diverticula and aids in staging the diverticulitis
¨ Stage I: Pericolic or mesenteric abscess: wait-and-see management. If the
abscess cannot be drained or it is refractive to pharmacologic therapy, we
perform surgery
¨ Stage II: Walled-off pelvic abscess
¨ Stage III: Generalized purulent peritonitis
¨ Stage IV: Generalized fecal peritonitis
The classification is based on the CT examination images and is basic in order to
understand either the patient needs surgery or not.
§ Appropriate treatment must be individualized based on the severity of the disease
§ The Hinchey classification divides the particular perforations into four stages. Mortality
increases significantly in stages III and IV.
CLINICS
ranges from asymptomatic to generalized peritonitis
o We have three main symptoms: fever, bowel changes (e.g. constipation, paralytic ileus), and pain
o LLQ pain/tenderness (2/3 of patients) often for several days before admission. Possible radiation to
the suprapubic area, left groin, or back
The most common physical findings are:
Tenderness of the left lower abdomen
§ Alterations in bowel habits
§ Fever
§ Chills
§ Urinary urgency
§ Rectal bleeding is not usually associated
§ Other possible symptoms: constipation, diarrhea, N/V, urinary symptoms (with adjacent inflammation)
