Diverticulosis Flashcards
Four different manifestations of diverticulum
- Diverticulosis - presence of diverticula
- Diverticular disease - symptoms arising from diverticula
- Diverticulitis - inflammation of diverticula
- Diverticular bleed - erodes vessel and causes large volume painless bleed
Pathophysiology of diverticulosis
- 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
What can then happen within these outpouchings?
- Bacteria can overgrow
- Leading to inflammation of diverticulum = diverticulitis
- These can sometimes perforate –> peritonitis and sepsis
What can occur in chronic diverticulitis?
- Fistula can form
- Colovesical or colovaginal are common
Complicated vs simple diverticulitis
- Complicated = presence of abscess or free perforation
- Simple = inflam without these^
RF for diverticulosis
- Age
- Low dietary fibre - constipation increases pressure
- Obesity
- Smoking
- FH
- NSAID use
Diverticulosis symptoms
- Asymptomatic
- Incidental finding on CT or colonoscopy
Diverticular disease symptoms
- Intermittent lower abdominal pain
- Colicky
- Relieved by defecation
- Can also have altered bowel ahbit, nausea and flatulence
Acute diverticulitis symptoms
- Acute abdominal pain - sharp, localised to LIF, worsened by movement
- Nausea
- Loss of appetite
Examination findings for acute diverticulitis
- Localised tenderness
- Systemically unwell - pyrexia
- Localised peritonism if perforated diverticulum
What can mask or change symptoms of diverticulitis even if perforated?
- 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)
Diverticular abscess - management
- 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
Bedside and bloods for ?diverticulitis
- FBC, CRP, U&E
- Group and save
- VBG
- Urine dip to exclude urological
- Consider faecal calprotectin if diagnosis unclear
Imaging for ?diverticulitis and findings
- CT abdomen-pelvis
- Thickening colonic wall, pericolonic fat stranding (increased attenuation), abscesses, localised air bubbles or free air
What investigation should never be done in ?diverticulitis
- Colonoscopy - risk perforating
Investigation for uncomplicated diverticular disease
- Flexible sigmoidoscopy
- If not suitable, CT colonography is alternative
Classification of acute diverticulitis
Hinchey classification
Hinchey classification
- 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
Management uncomplicated diverticular disease
- Manage outpatient usually
- Simple analgesia
- Encourage oral fluid intake
- Outpatient colonoscopy to rule out masked malignancy
Management diverticular bleeds
- Conservative
- If significant bleeding - blood products and stablise
- If fail to respond conservatively - embolisation or surgical resection
When can uncomplicated diverticular disease require admission?
- Uncontrolled pain
- Dehydration
- Immunocompromise
- Significant co-morbids
- PR bleeding
- Persistent symptoms >48hrs using conservative management
Management acute diverticulitis
Conservative:
* Antibiotics (oral if mild, IV if more severe)
* Liquid diet?
* IV fluids
* Analgesia
* Typically improve within 2-3 days
What to do if acute diverticulitis patient seems to deteriorate?
- Reassess - repeat imaging and check for progression/complication
Surgical interventions - when for diverticulitis
- Perforation with faecal peritonitis OR
- Overwhelming sepsis
Surgical procedure for severe diverticulitis
- Hartmanns
- Sigmoid colectomy with formation of end colostomy
- Anastomosis with reversal colostomy considered at later date
Complications of diverticulosis
- Recurrence of diverticulitis
- Stricture
- Fistula
Diverticular stricture
- 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)
Diverticular fistula
- Due to repeated inflammation
- Always require surgery (mostly)
- Colovesical or colovaginal
Colovesical fistula
- Between bowel and bladder
- Present with recurrent UTI, pneumoturia or passing faecal matter in urine
Colovaginal fistula
- Between bowel and vagina
- Copious vaginal discharge or recurrent vaginal infections
