Gen Surg: Diverticular disease Flashcards

1
Q

What is a diverticulum?

A

An outpouching of the gut wall, usually at sites of entry of perforating arteries

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2
Q

What does diverticulosis mean?

A

Presence of diverticula, no inflammation

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3
Q

What does diverticulitis mean?

A

Inflammation of a diverticulum - most often occuring when faeces obstruct the neck of the diverticulum causing stagnation and allowing bacteria to multiply and produce inflammation. This can then lead to bowel perforation (peridiverticulitis), abscess formation, fistulae into adjacent organs, or even generalized peritonitis.

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4
Q

Where do diverticula most commonly occur?

A

Along the lines where the penetrating colonic arteries thransverse the colonic wall between the taenia coli

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5
Q

What is diverticular disease?

A

Diverticula associated wtih abdominal pain and disrupted bowel habit (ie symptomatic)

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6
Q

What is meant by the term diverticular colitis?

A

Refers to cresenteric inflammation on the folds in areas of diverticulosis

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7
Q

What is thought to be the cause of diverticulosis?

A

Unknown

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8
Q

How do diverticula form?

A

There is thickening of the muscle layer and, because of high intraluminal pressures, pouches of mucosa extrude through the muscular wall through weakened areas near blood vessels to form diverticula.

An alternative explanation is cholinergic denervation with increasing age which leads to hypersensitivity and increased uncoordinated muscular contraction.

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9
Q

What are symptoms of diverticulosis?

A

Majority asymptomatic, but if painful diverticular disease (most commonly affects sigmoid colon):

  • Altered bowel habit - constipation/flatulence
  • Left sided colic relieved by defecation
  • Rectal bleeding - can be massive
  • Nausea
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10
Q

What are symptoms of diverticulitis?

A

Features of diverticulosis, plus:

  • Pyrexia
  • Tender bowels
  • Localised/generalised peritoneal abdominal pain
  • Rebound tenderness
  • Constipation

Similar to features of acute appendicitis, but on the left hand side rather than the right

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11
Q

What would you find on examination of someone with diverticulitis?

A

Left side fo the abdomen

  • Tenderness
  • Guarding
  • Rigidity
  • Palpable tender mass - LIF
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12
Q

Where in the colon does diverticular disease most commonly affect?

A

Sigmoid colon

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13
Q

Why can severe pain and constipation occur in severe diverticulosis?

A

Due to luminal narrowing of the sigmoid colon

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14
Q

How is diverticulosis most commonly picked up?

A

Incidentaly on imaging

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15
Q

Why can some of those with diverticular disease present with blood in the stool?

A

Tends to be large volume, dark red clotted rectal blood - due to rupture of peridiverticular submucosal blood vessel

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16
Q

How would you investigate if you suspected diverticulosis?

A
  • Elective barium enema (seen below) (gastrogaffin)
  • Could consider colonoscopy + sigmoidoscopy - poor investigation for assessing number
  • Consider CT scan
  • CXR if perforation expected
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17
Q

How would you investigate someone for suspected acute diverticulitis?

A
  • Bloods - FBC, CRP
  • Abdo US
  • CT colonography
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18
Q

What might you see on CT in someone with acute diverticulitis?

A
  • Colonic wall thickening
  • Diverticula
  • Pericolic collections and abscesses
  • Streaky increased density extending into the immediate pericolic fat
  • Thickening of the pelvic fascial planes
19
Q

What would you not perform in an acute diverticulitis attack?

A

Colonoscopy/sigmoidoscopy

20
Q

What are complications of diverticular disease?

A
  • Pericolic/paracolic abscess
  • Peritonitis
  • Diverticular fistula
  • Stricture formation
  • Haemorrhage
21
Q

Why can peritonitis occur as a complication of diverticular disease?

A

Perforation of a pericolic/paracolic abscess leads to purulent peritonitis. Direct perforation of acute diverticular segment leads to faeculent peritonitis

22
Q

Why do pericolic/paracolic abscesses form in acute diverticulitis?

A

May progress to persistent pericolic infection with thickening of surrounding tissues and the formation of a mass. If this suppurates, a pericolic abscess forms

Enlargement and extension of this leads into the paracolic area -> paracolic abscess

23
Q

What are clinical features of a paracolic/pericolic abscess?

A

Symptoms/signs of acute diverticulitis, plus:

  • Swinging fever
  • Fluctuating tachycardia
  • Unresolved abdominal pain
  • Tender LIF mass
24
Q

How do diverticular fistulae form?

A

Acute infection with paracolic spesis may drain by perforation into adjacent structures. This is typically the posterior vaginal vault in women or bladder in either sex

25
Q

Where do diverticular fistulae commonly form?

A
  • Posterior vaginal vault
  • Colovesical fistula
26
Q

What are features of a colovesical fistula?

A
  • Recurrent UTIs
  • Pneumonuria
  • Debris in the urine
27
Q

What are features of a colovaginal fistula?

A

Faeculent PV discharge

28
Q

Why can you get stricture formation as a complication of diverticular disease?

A

Recurrent inflammation leads to fibrosis and narrowing of the collon

29
Q

What are features of stricture formation in diverticular disease?

A
  • Colicky abdo pain
  • Distention
  • Bloating
  • Constipation
30
Q

How would you manage diverticular disease?

A
  • High fibre diet
  • Antispasmodics if required - e.g. mebeverine
31
Q

How would you manage acute diverticulitis?

A
  • Mild - home with bowel rest and Abx (agumentin +/- metronidazole)
  • Severe - admit
    • NBM
    • IV fluids
    • Analgesia
    • Abx (cefuroxime + metronidazole)
    • Monitor for complications
32
Q

When would you admit someone with diverticulitis?

A

If unwell or fluids/pain can’t be tolerated/comorbidities/significant PR bleeding /suspicion of peritonitis

33
Q

What antibiotics would you use to treat diverticulitis?

A

3-7 days

  • IV Gentamicin + Metranidazole +/- Amoxicillin (in pen allergic - co-trimoxazole)
  • Switch to oral Metranidazole + doxycycline/Co-trimoxazole
34
Q

Indications for surgical management of diverticulitis

A

Perforation

Large haemorrhage

Stricture - obstruction

Failure to improve with conservative

Sepsis

35
Q

How would you manage perforation in diverticular disease?

A
  • Antibiotics
  • Segmental resection with Hartmann’s procedure
  • Consider anastamosis when peritonitis has resolved
36
Q

How would you manage major haemorrhage from diverticular disease?

A
  • Angiographic embolisation
  • Colonic resection
37
Q

What is a hartmann’s procedure

A

A proctosigmoidectomy - the surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy.

38
Q

How would you manage someone with a stricture caused by diverticular disease?

A

Elective resection or balloon dilatation

39
Q

When is resection indicated in diverticular disease?

A
  • Acute inflammation failing to respond to medical management
  • Undrainable paracolic sepsis
  • Free perforation
  • Stenosis
  • Fistulae
  • Recurrent bleeding
40
Q

How would you manage paracolic/pericolic abscess?

A

Antibiotics +/- ultrasound/CT-guided drainage me be needed

41
Q

What is a Meckel’s Diverticulum?

A

Meckel’s Diverticulum is a true congenital diverticulum - a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk).

42
Q

What is a Meckel’s Diverticulum a remnant of?

A

Omphalomesenteric duct (also called the vitelline duct or yolk stalk)

43
Q

Complications of diverticulitis

A

Perforation

Obstruction

Haemorrhage

Fistulae (Bladder - colovesicle, Vagina - colovaginal)

Abscess