Diverticulitis Of The Colon

Question 1

Difference between diverticulosis and diverticulitis

Answer 1

Diverticulosis = bleeding diverticula disease

• also is usually non-inflamed
• other than bleeding, there is usually no other symptoms
• • the bleeding is most common in the right colon

Diverticulitis = non-bleeding diverticula Disease

• also is usually inflamed
• there are symptoms but no bleeding

Question 2

Is it inflamed or non-inflamed diverticuli more likely to bleed?

Answer 2

Non-inflammed

Question 3

What is an ileus?

Answer 3

Ileus = intestines remain dilated and don’t undergo peristalsis
- is painful and is caused by distention

Question 4

Hinchey staging system

Answer 4

Classifies a colonic perforation due to diverticular diseases
- doesnt really helps treatment, but helps determine how bad or how severe it is (determines if emergency surgery is needed which is almost always in 3/4)

Hinchey 1 = localized abscesses that are para-colonic

Hinchey 2= pelvic abscesses

Hinchey 3 = Purulent peritonitis (usually without feces

Hinchey 4 = feculent peritionits (Purulent with feces

Question 5

What are diverticula

Answer 5

Are out-pouching or protrusions of all or a portion of the wall of a intestines

True = all layers of the intestinal wall

False = not all layers of the intestinal wall

• *they can occur anywhere in the GI tract but most commonly seen in:
• esophagus
• jejunum
• ileum
• colon
• ***sigmoid colon = 90%

meckels = true diverticula

Question 6

Pulsion vs traction diverticula

Answer 6

Pulsion = occurs due to increases intraluminal pressure often caused by spastic motility
- usually false diverticula

Traction = occurs due to extrinsic inflammation or forces/motility disorders that pulls the wall outwards
- usually true diverticula

Question 7

If a diverticulum is of congenital origin, is it likely true or false?

Answer 7

True diverticulum

Question 8

What’s one easy way to to differentiate acute from chronic diverticula?

Answer 8

Chronic = usually shows narrowing/strictures of the colon

Question 9

How to diagnose diverticula

Answer 9

Colonoscopy

Palpable on exam

Barium enema

Question 10

Symptoms of diverticula

Answer 10

usually asymptomatic

Symptoms:

• dull ache or sharp pain in the left lower quadrant
• usually acute onset of pain
• low grade fever
• (+/-) N/V
• narrowing of the stool

Question 11

Specific Pathology of colon diverticula

Answer 11

Believed to be primarily increased luminal pressure which causes herniation of the bowel wall at the weakest points

• usually between the antimesenteric longitudinal taenia coli muscle bands and between the circular muscle rings
• this is often the site where blood vessels are located also

Question 12

Common known causes of increased risk for diverticula

Answer 12

Low fiber diets**
- however, high fiber diets = frequent bowel movements so both sides of the spectrum increase diverticula

Alcohol consumption

Elevated elastin levels

Frequent bowel movements

• Note:**
• high body mass index, lack of physical activity, lack of bowel habits ARE NOT associated with an increase in diverticula

Question 13

What is the most common colonic diverticula for children?

Answer 13

Right sided colonic diverticula or decal diverticulosis

Question 14

How to diagnose colonic diverticulitis

Answer 14

Any of the following can be used:

• barium enema
• colonoscopy (#2)
• abdominal CT scan (#1)
• nuclear medicine bleeding scans (only if actively ruptured)
• angiography

endoscopy and CT scan are especially useful for pharyngeal,esophageal and small intestinal diverticula

active bleeding requires angiography or bleeding scans usually

barium enemas should be used with caution since the barium can impact in the diverticula and cause damage

Question 15

What is the most common site of diverticula in adults?

Answer 15

Sigmoid colon

Question 16

What is the saint triad?

Answer 16

A relationship between the following which often occur together (especially in the western world)

1) cholelithiasis (gallstones)
2) hiatal hernia
3) Diverticulitis

isnt really used diagnostically however

Question 17

Diverticula disease symptoms

Answer 17

Symptoms:

• painless bleeding (diverticulosis only)
• fever
• leukocytosis
• lower ab pain (usually LLQ)
• tenesmus
• diarrhea or constipation
• urinary symptoms (if fistula is present usually)

sometimes is called “left sided appendicitis”

Question 18

Can diverticulosis occur in the rectum?

Answer 18

NO
- diverticulosis is limited to a portion of the colon above the pelvic peritoneal reflection (aka sigmoid colon and above)

Question 19

What are the most common complications of diverticula disease

Answer 19

1) infections/abscess
- #1 most common complication

2) bleeding

3) Fistula formation
- **most common is colo-vesical (bladder with colon)

4) stricture obstruction
- long term inflammation causes narrowing of the bowel

5) perforation and sepsis/peritonitis

Question 20

What is the hinchey classification

Answer 20

Useful in describing severity of diverticula disease and its staging
- not overly useful for treatment consideration though

Stages:
1) localized pericolic abscess are present

2) pelvic abscess is present and is sealed off/contained
- there is usually bacteria in the peritoneal cavity though

3) perforated diverticulum are present and results in Purulent peritonitis that is not walled off
- either one diverticula or abscess is perforated and spilling into peritoneal cavity

4) perforated diverticulum are present with fecal and pus peritonitis
- the perforation is gross and there is fecal spillage directly into the peritoneal cavity

Question 21

How to deal with bleeding in diverticulosis

Answer 21

• note: roughly 80% will stop without intervention*
• usually just treat conservatively

Options if conservative options dont work:

• angiographic control
• colonoscopic injection with saline and epinephrine
• barium enemas
• surgical resection

Question 22

When should someone’s first colonoscopy begin?

Answer 22

Either (age of first degree relatively diagnosed with colon cancer -10yrs) or once you hit 50 yrs
- which ever is less

Question 23

Treatment of infectioous diverticulitis

Answer 23

Uncomplicated (no perforation, obstruction or fistula present)

• GI tract rest and IV antibiotics
• ciprofloxacin is the #1 used

Complicated
- IV antibiotics, GI tract rest and either surgical intervention or bowel resection

Question 24

What is the Hartmann procedure?

Answer 24

Resection of diverticulitis colon and then rectum is diverted through the umbilicus (colostomy bag is needed)

Question 25

What is the best diagnostic study to evaluate for diverticulitis?

Answer 25

Abdominal CT scans

colonoscopy is the 2nd best one

Question 26

Where along a section of colon would a diverticuli most likely occur?

Answer 26

Where vessels pierce the muscular wall of the muscularis mucosa

Question 27

Are false or true diverticuli more common?

Answer 27

False/pseudo
- only includes the mucosa and Submucosa layers

True = contains all layers of the colon

Question 28

What is the best test used to determine a fistula that is a complication of diverticulitis?

Answer 28

Barium enemas

- colonoscopy might not catch it and CT wont