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General surgery + HPB - YR3 > Diverticulosis > Flashcards

Diverticulosis Flashcards

1
Q

Four different manifestations of diverticulum

A
  • Diverticulosis - presence of diverticula
  • Diverticular disease - symptoms arising from diverticula
  • Diverticulitis - inflammation of diverticula
  • Diverticular bleed - erodes vessel and causes large volume painless bleed
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2
Q

Pathophysiology of diverticulosis

A
  • Aging bowel - naturally weakened over time
  • Movement of stool within lumen = increased intraluminal pressure
  • = outpouchings of mucosa through weaker areas of bowel
  • These areas are usually where blood vessels penetrate to supply bowel and can also happen at junctions of triangular muscle sheets
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3
Q

What can then happen within these outpouchings?

A
  • Bacteria can overgrow
  • Leading to inflammation of diverticulum = diverticulitis
  • These can sometimes perforate –> peritonitis and sepsis
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4
Q

What can occur in chronic diverticulitis?

A
  • Fistula can form
  • Colovesical or colovaginal are common
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5
Q

Complicated vs simple diverticulitis

A
  • Complicated = presence of abscess or free perforation
  • Simple = inflam without these^
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6
Q

RF for diverticulosis

A
  • Age
  • Low dietary fibre - constipation increases pressure
  • Obesity
  • Smoking
  • FH
  • NSAID use
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7
Q

Diverticulosis symptoms

A
  • Asymptomatic
  • Incidental finding on CT or colonoscopy
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8
Q

Diverticular disease symptoms

A
  • Intermittent lower abdominal pain
  • Colicky
  • Relieved by defecation
  • Can also have altered bowel ahbit, nausea and flatulence
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9
Q

Acute diverticulitis symptoms

A
  • Acute abdominal pain - sharp, localised to LIF, worsened by movement
  • Nausea
  • Loss of appetite
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10
Q

Examination findings for acute diverticulitis

A
  • Localised tenderness
  • Systemically unwell - pyrexia
  • Localised peritonism if perforated diverticulum
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11
Q

What can mask or change symptoms of diverticulitis even if perforated?

A
  • If taking corticosteroids or immunosupressants
  • Also if redundant sigmoid colon, pain may be RLQ or suprapubic (too long, needs to fold/twist to fit inside)
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12
Q

Diverticular abscess - management

A
  • Occur as part of complicated diverticulitis (AKA paracolic abscess)
  • If <5cm - conservative with IV abx
  • If any bigger - radiological drainage 1st line
  • If complicated multiloculated (or if clinically deteriorate) –> surgery either laparascopic washout or Hartmanns
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13
Q

Bedside and bloods for ?diverticulitis

A
  • FBC, CRP, U&E
  • Group and save
  • VBG
  • Urine dip to exclude urological
  • Consider faecal calprotectin if diagnosis unclear
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14
Q

Imaging for ?diverticulitis and findings

A
  • CT abdomen-pelvis
  • Thickening colonic wall, pericolonic fat stranding (increased attenuation), abscesses, localised air bubbles or free air
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15
Q

What investigation should never be done in ?diverticulitis

A
  • Colonoscopy - risk perforating
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16
Q

Investigation for uncomplicated diverticular disease

A
  • Flexible sigmoidoscopy
  • If not suitable, CT colonography is alternative
17
Q

Classification of acute diverticulitis

A

Hinchey classification

18
Q

Hinchey classification

A
  • Stage 1 - phlegmon or diverticulitis with paracolic or mesenteric abscess
  • Stage 2 - diverticulitis with walled off pelvic abscess
  • Stage 3 - diverticulitis + generalised purulent peritonitis
  • Stage 4 - diverticulitis + generalised faecal peritonitis
19
Q

Management uncomplicated diverticular disease

A
  • Manage outpatient usually
  • Simple analgesia
  • Encourage oral fluid intake
  • Outpatient colonoscopy to rule out masked malignancy
20
Q

Management diverticular bleeds

A
  • Conservative
  • If significant bleeding - blood products and stablise
  • If fail to respond conservatively - embolisation or surgical resection
21
Q

When can uncomplicated diverticular disease require admission?

A
  • Uncontrolled pain
  • Dehydration
  • Immunocompromise
  • Significant co-morbids
  • PR bleeding
  • Persistent symptoms >48hrs using conservative management
22
Q

Management acute diverticulitis

A

Conservative:
* Antibiotics (oral if mild, IV if more severe)
* Liquid diet?
* IV fluids
* Analgesia
* Typically improve within 2-3 days

23
Q

What to do if acute diverticulitis patient seems to deteriorate?

A
  • Reassess - repeat imaging and check for progression/complication
24
Q

Surgical interventions - when for diverticulitis

A
  • Perforation with faecal peritonitis OR
  • Overwhelming sepsis
25
Q

Surgical procedure for severe diverticulitis

A
  • Hartmanns
  • Sigmoid colectomy with formation of end colostomy
  • Anastomosis with reversal colostomy considered at later date
26
Q

Complications of diverticulosis

A
  • Recurrence of diverticulitis
  • Stricture
  • Fistula
27
Q

Diverticular stricture

A
  • Following repeated episodes of acute inflammation
  • Scarred, fibrotic bowel = benign stricture
  • Can cause LBO –> sigmoid colectomy urgent or elective dependent on presentation (stenting can be used temporarily)
28
Q

Diverticular fistula

A
  • Due to repeated inflammation
  • Always require surgery (mostly)
  • Colovesical or colovaginal
29
Q

Colovesical fistula

A
  • Between bowel and bladder
  • Present with recurrent UTI, pneumoturia or passing faecal matter in urine
30
Q

Colovaginal fistula

A
  • Between bowel and vagina
  • Copious vaginal discharge or recurrent vaginal infections

General surgery + HPB - YR3 (38 decks)

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