Ischaemic colitis and diverticulitis Flashcards

1
Q

Outline the pathology of ischaemic colitis

A

Compromised perfusion to the marginal branches of the middle colic (SMA) and left colic (IMA) that supply the transverse and descending colon.

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2
Q

Which area of the colon is particularly susceptible to ischaemic colitis?

A

Splenic flexure

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3
Q

Name 3 predisposing factors for ischaemic colitis

A
Thrombosis of IMA
AAA repair commonly ligates IMA
Emboli
Decreased CO or arrhythmias
Shock
Trauma
Strangulated hernia or volvulus
Drugs: OCP, cocaine, antihypertensives, psychotropic
Abdominal surgery
Vasculitis
Coagulation disorders
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4
Q

Describe the presentation of ischaemic colitis

A

Sudden onset of abdominal pain, commonly in LIF
-typically occurs after eating
-pain out of proportion to clinical findings
Bright red PR bleeding
NaV
Diarrhoea

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5
Q

How should ischaemic colitis be investigated?

A

Urgent CT to exclude perforation
AXR would show thumb printing
Flexible sigmoidoscopy
Biopsy ➔ epithelial cell apoptosis and lamina propriety fibrosis

Later: Colonoscopy to exclude strictures and confirm mucosal healing

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6
Q

How is ischaemic colitis managed?

A

Many cases are resolved by correcting hypoperfusion
Symptomatic treatment
Surgery if fulminant ischaemic colitis + perforation/gangrene

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7
Q

Define diverticulum

A

Herniation of mucosa through thickened colonic muscle

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8
Q

Where are diverticula most commonly seen?

A

Sigmoid (85%) and descending colon

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9
Q

What lifestyle factor is diverticulum formation associated with?

A

Low-fibre diet - seen most in USA, Europe, and Australia

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10
Q

Name and describe the 3 conditions associated with diverticula

A

Diverticulosis (95%): Presence of asymptomatic diverticula
Diverticular disease: Symptomatic diverticula
Diverticulitis: Diverticular inflammation

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11
Q

What percentage of people aged 50+ have diverticula?

A

50%

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12
Q

Name 3 risk factors for diverticular disease

A

Aged 50+
Low fibre diet
Obesity

Complicated diverticular disease is commoner in patients who smoke, use NSAIDs, obese, low-fibre diets.

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13
Q

How does diverticulosis present?

A

Frequently an incidental finding on colonoscopy or barium enema.

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14
Q

How does diverticular disease present?

A

Large painless rectal bleed
Nonspecific abdominal complaints, usually left-sided:
-Intermittent lower abdominal/LIF pain
-Erratic bowel habit

Severe disease ➔ severe pain and constipation

Pain exacerbated by eating, diminished with defecation or flatus

NB. Isolated diverticular bleeds in absence of infection tend to spontaneously resolve ➔ active observation

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15
Q

How does diverticulitis present?

A
Severe lower abdominal pain
Fever
Malaise
Change in bowel habit
Rectal bleeding (occasional)
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16
Q

Name 4 complications of diverticulitis

A
Rectal bleeding (5-10%)
Abscess
Peritonitis
Fistula
Obstruction/stricture
Perforation

N.B. 25% of acute diverticulitis is ‘complicated’

17
Q

How should diverticular disease be investigated?

A

FBC ➔ inflammation in acute episodes
VBG ➔ lactate rule out mesenteric ischaemia
Colonoscopy: contraindicated in acute diverticulitis
Barium enema if uncomplicated
Erect CXR ➔ pneumoperitonium
AXR ➔ bowel obstruction, abscess
CT ➔ complicated diverticular disease

18
Q

What is the management of diverticulosis?

A

Healthy high-fibre diet

Fluid intake

19
Q

Outline the medical management of diverticular disease

A

Healthy high-fibre diet and fluids
Weight loss and smoking cessation

Laxatives
Analgesia

20
Q

Outline the medical management of diverticulitis

A

Broad spectrum oral ABX
Analgesia
Clear liquids only ➔ gradual reintroduction of solid food
Check WCC and CRP for infection

21
Q

What are the surgical indications for diverticulitis?

A

Acute complicated diverticulitis

Not improving with medical treatment

22
Q

Outline the surgical treatment of diverticulitis

A

Sigmoid resection +/- colostomy
Percutaneous drainage of abscesses
Peritoneal lavage

23
Q

What medication increases the risk of bleeding in diverticular disease

A

NSAIDs e.g. Diclofenac for arthritis pain

24
Q

How should acute diverticulitis be followed-up?

A

Colonoscopy 2-6wk after resolution: confirms diagnosis, looks at complications such as strictures, and rules out other pathology such as colitis or carcinoma.

Advice to maintain high-fibre diet

25
Q

Outline the Hinchey classification

A

Used to describe perforated acute diverticulitis
I. Pericolic or mesenteric abscess
II. Walled-off pelvic abscess
III. Generalised purulent peritonitis (5% mortality)
IV. Generalised faecal peritonitis (35% mortality)

May be used as a guide to the suitability for primary anastomosis following resection