Diverticular disease

Question 1

Define diverticulosis and diverticulitis

Answer 1

Diverticulosis = Presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel, usually asymptomatic

Diverticulitis = acute inflammation and infection of colonic diverticulae

Question 2

How is diverticular disease classified

Answer 2

Hinchey classification
0: Mild clinical diverticulitis
Ia: Phlegmon/confined inflammation
Ib: localised abscesses
II: Pelvic, distant abscess
III: Perforation with purulent peritonitis
IV: Faecal peritonitis

Question 3

Aetiology of diverticular disease

Answer 3

Diverticulae consist of herniated mucosa and submucosa through the muscularis.
Raised intra-luminal pressure
Most common in the sigmoid and descending colon, but can be right sided (Absent from the rectum)
Diverticular obstruction by inspissated faeces → bacterial overgrowth, toxin production, mucosal injury + diverticulitis, perforation, pericolic phlegmon, abscess, ulceration and fistulation/stricture formation

Question 4

Risk factors for diverticular disease

Answer 4

Low dietary fibre
Age >50 years
Western diet and sedentary lifestyle
Obesity
NSAIDs, steroids
Hiatus hernia + gall stones (Saint’s triad)
Smoking
Alcohol consumption
Ehlers Danlos

Question 5

Epidemiology of diverticular disease

Answer 5

Increased prevalence with age
Lower incidence in vegetarians
More aggressive form manifests in younger obese males

Question 6

Symptoms of diverticular disease

Answer 6

Often asymptomatic

Bloody stool
LIF pain
Fever
Urinary symptoms*
Bloating
Constipation

*Due to fistulation into the bladder - pneumaturia, faecaluria and recurrent UTIs

Question 7

Signs of diverticular disease on examination

Answer 7

Obs: fever

Abdo:
- Abdo tenderness, LIF, pelvic, diffuse
- Palpable abdo mass
- Peritonitis signs (rebound tenderness, guarding, rigidity)

Question 8

Investigations for diverticular disease

Answer 8

Urine dip + pregnancy test

FBC: Leukocytosis
CRP: raised
Coagulation, X-match, G&S: ?surgery

AXR: ?perforation, ileus,
CXR: ?perforation
CT abdomen: evidence of diverticular disease, thickening of bowel wall, masses, abscess, streaky mesenteric fat
Sigmoidoscopy and colonoscopy: Visualise diverticulae
Barium enema: for CHRONIC disease, shows saw-tooth appearance of lumen (pseudohypertrophy or circular muscle)

Question 9

Management of diverticulosis

Answer 9

Asymptomatic: None required

Symptomatic:
- Dietary modification
- Oral antibiotic therapy e.g. amoxicillin
- Colonoscopy in 6-8 weeks to check for malignancy

Question 10

Management of diverticulitis

Answer 10

Uncomplicated:
- Analgesia
- PO ABx e.g. amoxicillin → IV ABx
- Low residue-diet

Complicated:
- Endoscopic haemostasis for any bleeds
- Supportive (Fluids, analgesia) + Abx e.g. amoxicillin PO/IV
- Low residue-diet and bowel rest
- Consider primary anastamosis

Recurrent: Colectomy (Hartmann’s (open), laparoscopy)

Question 11

Complications of diverticular disease

Answer 11

Diverticulitis
Fistula
Colorectal neoplasm
Abscess i.e. pericolic abscess
Perforation
Strictures and obstruction
Faecal peritonitis

Question 12

Prognosis for diverticular disease

Answer 12

Uncomplicated diverticulitis will recover following medical treatment
Diverticular disease recurs in 1/3 patients following response to medical treatment
Risk of recurrence is higher in younger patients
Recurrent disease is associated with high mortality, and therapy response is less favourable
1/4 of all patients continue to remain symptomatic after surgery