Diverticulitis + Endometriosis (18)

Question 1

What is diverticulosis?

Answer 1

• Diverticulosis is the result of unique structure of the colonic muscularis propria and elevated intraluminal pressure in the sigmoid colon.
• Increased intraluminal pressure is probably due to exaggerated peristaltic contractions, with spasmodic sequestration of bowel segments, and may be enhanced by diets low in fiber, which reduce stool bulk, particularly in the sigmoid colon.

Question 2

What are the complications of diverticular disease?

Answer 2

• Infections
• Diverticulitis
• Perforation, paracolic abscess, focal peritonitis
• Fistula (colovesical, vaginocolic, ileocolic)
• Bleeding
• I.O

Question 3

What is the cause of diverticulitis in diverticular disease?

Answer 3

• Obstruction of diverticula leads to inflammatory changes, producing diverticulitis and peridiverticulitis.
• Because the wall of the diverticulum is supported only by the muscularis mucosa and a thin layer of subserosal adipose tissue, inflammation and increased pressure within an obstructed diverticulum can lead to perforation.

Question 4

What is the Hinchey classification for perforated diverticulitis?

Answer 4

• I Pericolic abscess
• IIa Distant abscess amenable to percutaneous drainage
• IIb Complex abscess associated with fistula not amenable to percutaneous drainage
• III Generalized purulent peritonitis
• IV Fecal peritonitis

Question 5

What are the management options for diverticulitis?

Answer 5

• Conservative (for uncomplicated diverticulitis):
  
  • Fluids
  • NPO
  • Antibiotics
  • CT guided percutaneous drainage of collection should be considered
• Surgery (perforations): staged procedure:
  
  • Diverting colostomy
  • Hartmann
  • Resection anastomoses

Question 6

What investigations are done for diverticulitis?

Answer 6

• FBC
• Urine
• CXR and AXR
• Rigid sigmoidoscopy
• Barium enema
• CT abdomen

Question 7

How do neutrophils migrate to the site of infection?

Answer 7

• Margination and rolling along the vessel wall
• Firm adhesion to the endothelium
• Transmigration between endothelial cells
• Migration in interstitial tissues toward a chemoattractant stimulus

Question 8

How can endometriosis get to the colon?

Answer 8

• Regurgitation theory: via retrograde flow of menstrual endometrium
• Benign metastases theory: via blood vessels and lymphatic channels
• Metaplastic theory: from coelomic epithelium or mesonephric remnants
• Extrauterine stem/progenitor cell theory: via differentiation of bone marrow stem/progenitor cells

Question 9

What is the intraperitoneal picture of endometriosis?

Answer 9

Burn powder, dark blue, black, chocolate cysts

Question 9

What is the epithelium of the uterus like?

Answer 9

• Simple columnar supported by thick vascular stroma
• The endometrium is the inner epithelial layer with a basal layer and a functional layer that thickens and is sloughed during the menstrual cycle

Question 10

Can endometriosis increase the risk of cancer?

Answer 10

Yes, especially ovarian cancer (3.5-fold risk increase)

Question 11

Why does endometriosis cause pain?

Answer 11

Due to intrapelvic bleeding and periuterine adhesions

Question 12

Why did the patient develop a LIF collection a few days later?

Answer 12

Due to a retained collection (pelvic abscess)

Question 13

What antibiotics should be given?

Answer 13

• Amoxicillin clavulanic (1.2 g BD for 7 days) to cover gram-positive organisms
• Gentamycin (80 mg BD for 3 days) to cover gram-negative organisms
• Clindamycin (600 mg BD for 5 days) to cover anaerobes

Question 14

Define the following: Diverticulosis, Diverticular disease, Diverticulitis?

Answer 14

• Diverticulosis: presence of diverticula that are asymptomatic
• Diverticular disease: diverticula associated with symptoms
• Diverticulitis: evidence of diverticular inflammation (fever, tachycardia) with or without localized symptoms and signs