GI - Diverticular Disease

Question 1

Definition

• Diverticulum
• true vs false
• diverticular disease
• diverticulitis

Answer 1

• Diverticulum: out-pouching of tubular structure
• True: composed of complete wall (eg Meckel’s)
• False: composed of mucosa only (pharyngeal/colonic)
• Diverticular disease: symptomatic diverticulosis
• Diverticulitis: inflammation of divertiula

Question 2

epidemiology

Answer 2

• Female > male

- more common in Caucasians

Question 3

Pathophysiology

Answer 3

• Associated with increased intraluminal pressure (need fibre in diet!)
• Mucosa herniates through muscularis propria at points of weakness (where performating arteries enter)
• Most commonly located in sigmoid colon
• More common in obese pts

Question 4

Symptoms of diverticular disease

-Treatment for symptom relief

Answer 4

• Altered bowel habit +- left sided colic (relieved by defecation)
• nausea
• flatulence
• Rx: high fibre diet

Question 5

What is diverticulitis?

Answer 5

• '’Left sided appendicitis’’
• Inspissated faeces lead to obstruction of diverticulum
• occurs in elderly pts with Hx of constipation

Question 6

Presentation of diverticular disease

Answer 6

• Abdo pain and tenderness (typically LIF and localised peritonitis)
• PR bleeding (usually suddent and sometimes painless - large amount of blood and clots may be passed)
• Pyrexia
• Anorexia, nausea or vomiting
• Severe chronic cases: fistulae can form (colovesical/colovaginal)

Question 7

Differential

Answer 7

• IBD and Bowel cancer (most important)
• Appendicitis, mesenteric ischaemia, renal stones, gynae cause
• Must investigate any pt with suspective diverticular D with imaging

Question 8

Ix- Bloods

Answer 8

• FBC (raised WCC)
• CRP (raised)
• Amylase
• Group and Save + cross match
• Urine dipstick
• ABG (lactate level - if suspect sepsis/bowel ischaemia)

Question 9

Ix- imaging

Answer 9

• Endoscopy: flexi sig or colonoscopy (not in acute attack)
• AXR (to exclude obstruction)
• eCXR (if perforation suspected)
• CT abdo-pelvis: perf/alternative Dx suspected/fistula Ix

Question 10

Mx- mild uncomplicated

Answer 10

• Mild/uncomplicated pts can be managed at home
• ABX, analgesia and encouraged intake of clear fluids (bowel rest)
• Analgesia: paracetamol (avoid opioid based b/c cause constipation)

Question 11

Mx- criteria for admission

Answer 11

• Pain not controlled with simple analgesia
• Dehydration concern
• Pt immunocompromised/co-morbid
• Significant PR bleeding
• Peritonitis suspicion
• Symptoms >48 hours with conservative Mx

Question 12

Mx - Medical/non surgical Mx

Answer 12

• NBM
• IV fluids
• Analgesia
• ABX: cefuroxime + metro (check local trust guidelines)
• most cases should settle with this

Question 13

Mx- Surgical

Answer 13

• Indication for surgical procedure: perf, large haemorrhage, stricture (obstruction)
• Emergency procedures: Bowel resection (with primary anastomosis or Hartmann’s procedure) or laprasocopic peritoneal lavage

Question 14

-What is a Hartmann’s procedure?

Answer 14

• Emergency surgical procedure
• Affected area of colon is resected, with formation of end colostomy and closure of rectal stump
• Anastomosis with reversal of colostomy may be possible at later date

Question 15

Possible complications of diverticular disease

Answer 15

• Perforation
• Haemorrhage
• Abscess
• Fistulae
• Strictures