Diverticulutis Flashcards
What are diverticula vs diverticulosis vs divertivicular disease vs diverticulitis?
- Diverticula are mucosal out-pouches (herniation of mucosa and submucosa through the muscularis) in the colonic musculature.
- The presence of diverticula without symptoms is called diverticulosis.
- Diverticular disease is symptomatic diverticula with no inflammation or infection.
- When these diverticula become inflamed, this results in diverticulitis
Are diverticula normal?
Diverticula occur when there is high intraluminal pressure within the bowel, which causes thinning of the bowel wall. Pouches of mucosa push through and develop into an outpouch
What causes diverticulitis?
Inflammation is believed to be caused by bacterial overgrowth and translocation through the colonic mucosa, but the exact aetiology is unknown
What are risk factors of diverticulosis and diverticulitis?
Risk factors for diverticulosis and diverticulitis include:
- Older age: in adults older than 85, 80% have diverticulosis
- Low-fibre diet (usually Western diets)
- Smoking
- Obesity
- Alcohol
- Medication: NSAIDs and opioids increase the risk of perforated diverticulitis
Where can diverticulae occur?
Diverticulae can occur throughout the gastrointestinal tract but are more common in the sigmoid & descending colon.
Age and presence of diverticulae
10% of people <40
50% of people >50
Symptoms of diverticulitis
Typical symptoms of diverticulitis include:
- Abdominal pain: most commonly in the left lower quadrant
- Change in bowel habit: diarrhoea or constipation
- Rectal bleeding
- Bloating
- Nausea and vomiting
- Anorexia
Divided based on classification:
- Incidental diverticulosis (e.g. visible on CT scan) = asymptomatic
- Uncomplicated diverticulitis = LLQ pain, change in bowel habit, fever, LGI bleed, abdominal mass
- Complicated diverticulitis = as above +/- peritonitis (rigidity, guarding, shock) +/- fistulas
Clinical examination findings in diverticulitis
Typical clinical findings of diverticulitis include:
- Tender abdomen +/- guarding
- Tachycardia
- Fever
Complications of diverticulitis
Complications of diverticulitis include:
Abscess formation
Perforation leading to peritonitis
Sepsis
Fistulation
Bowel obstruction
Bleeding
What is a fistula?
abnormal connection between two epithelial surfaces (e.g. bowel to bladder aka colo-vesicular fistula)
DDx for diverticulitis
The main gastrointestinal conditions to consider include:
Inflammatory bowel disease
Ischaemic colitis
Colorectal cancer
Irritable bowel syndrome
Appendicitis
The sigmoid colon is mobile within the abdomen and may move to the right iliac fossa. This may mimic other conditions, such as appendicitis.
Gynaecological and urological differentials such as ectopic pregnancy, ovarian pathology or renal/ureteric stones are also important to consider
Imaging in diverticulitis
Relevant imaging may include:
- CT abdomen and pelvis with contrast: if contraindicated (e.g. AKI), then a non-contrast CT scan can be requested
- CT angiogram (if finding a large diverticular bleed)
Hinchey classification
Stage 1 = localised pericolic abscess
Stage 2 = large pericolic or mesenteric abscess
Stage 3 = small perforation (small amount of gas/liquid escaping into abdomen)
Stage 4 = large perforation (faeces escaping into abdomen)
Management of diverticulitis
- Can be divided into lifestyle management, medical management, surgical management
- Most patients will be managed medically. However, surgical intervention may be required if this fails or complications occur.
Medical management of diverticulitis
- Uncomplicated diverticulitis can be managed as an outpatient without antibiotics if there is no evidence of complications, comorbidities or immunosuppression. They should be followed up after the flare.
- Patients should receive antibiotics for acute episodes of complicated diverticulitis. Depending on the severity, this could be oral or intravenous. Co-amoxiclav for five days is commonly used for acute diverticulitis. Those with penicillin allergies may receive co-trimoxazole and metronidazole (always refer to local guidelines).
- IV fluid should be considered if the patient appears dehydrated or is nil-by-mouth before surgery.1,4
- Analgesia should be used and titrated as per the WHO pain ladder.
Describe Hartman’s procedure
This involves a sigmoid colectomy and the formation of an end colostomy. An anastomosis and colostomy reversal can be performed once the patient has recovered from the acute illness. This carries a high risk and may not be completed in every patient.
Describe primary anastomosis
- This procedure involves resecting the diseased bowel (i.e. sigmoid colectomy) and forming an anastomosis between a healthy proximal margin and the rectum. - A loop ileostomy may be used short-term if the surgeon is concerned about anastomotic breakdown.
