DIVERTICULAR COLONIC DISEASE Part 2

Question 1

What is the role of abdominal radiography (plain films) in the initial evaluation of diverticulitis?

Answer 1

Abdominal radiography (plain films) is a good initial step.

It can show signs of ileus, occlusion, mass effect, perforation.

Question 2

What are the advantages and limitations of ultrasonography (US) in evaluating acute diverticulitis?

Answer 2

Advantages: Non-invasive and can be a safe examination.

Limitations: 20% of examinations are sub-optimal due to aerocolia and it is very operator-dependent.

Question 3

When is computer tomography (CT) particularly useful in cases of diverticulitis?

Answer 3

CT is very useful in complications.

CT evaluation for other diseases should be taken into account in all cases of diverticulitis associated with a palpable mass.

CT evaluation is warranted when the patient’s condition is severely affected.

Question 4

When is colon enema (irrigography) with water-soluble contrast considered safe and useful in cases of diverticulitis?

Answer 4

In cases of moderate severity, when the diagnosis is in doubt, the examination is safe and useful.

Question 5

What is the contraindication for colonoscopy in diverticulitis?

Answer 5

Acute diverticulitis is a contraindication for endoscopy; perforation should be excluded first.

Question 6

When does colonoscopy apply in the context of diverticulitis?

Answer 6

It applies only if the diagnosis could not be established by other methods.

When the symptoms of the ringing are represented by anemia, rectorrhagia.

For the exclusion of other diseases: ischemic colitis, ulcerative colitis, Crohn’s disease, CCR (colorectal cancer).

Question 7

CT Scan

Answer 7

➢ Marked thickening of distal end
of the descending colon
➢ Inflammatory changes (straight
arrow)
➢ Extraluminal gas (curved arrow)

Question 8

How does a peridiverticular abscess develop?

Answer 8

The result of the spontaneous evolution of a perforation with suprainfection.

Question 9

What are the possible outcomes of suppuration in peridiverticular abscess?

Answer 9

Due to the antibiotic treatment administered in the constitution phase, the suppuration can be reabsorbed or remains circumscribed.

Question 10

Where can a peridiverticular abscess open?

Answer 10

The abscess can open in a cavitary organ in the vicinity, in the skin, or in the peritoneal cavity.

Question 11

What are possible distant complications of peridiverticular abscess?

Answer 11

Pylephlebitis
Liver abscess

Question 12

How is peridiverticular abscess diagnosed?

Answer 12

Diagnosis – CT and/or US

Question 13

What are the two types of secondary peritonitis that can occur in diverticulitis?

Answer 13

Purulent / stercoral

Question 14

What is the clinical picture of secondary peritonitis in diverticulitis?

Answer 14

Brutal pain in the left iliac fossa

Signs of shock

High fever

Question 14

What are the abdominal findings on physical examination in secondary peritonitis?

Answer 14

Localized / generalized abdominal contracture

Question 15

What are the auscultation findings in secondary peritonitis?

Answer 15

Decreased bowel sounds

Question 16

What are the signs of pneumoperitoneum in secondary peritonitis?

Answer 16

Clinical signs of pneumoperitoneum with disappearance of liver dullness

Question 17

What is a fistula?

Answer 17

A fistula is an abnormal connection of tissue between two organs or between an organ and the skin.

Question 18

How do fistulas form in the context of infection?

Answer 18

When damaged tissues come into contact with each other during infection, they sometimes stick together; if they heal that way, a fistula may form.

Question 19

How do fistulas develop in diverticulitis?

Answer 19

When diverticulitis-related infection spreads outside the colon, the colon’s tissue may stick to nearby tissues.

Question 20

What organs are commonly involved in fistulas related to diverticulitis?

Answer 20

The organs usually involved are the bladder, small intestine, and the skin.

Question 21

What is the most common type of fistula in diverticular disease?

Answer 21

The most common type of fistula occurs between the bladder and the colon.

Question 22

Who is more often affected by colovesical fistulas?

Answer 22

This type of fistula affects men more often than women.

It can result in a severe, long-lasting infection of the urinary tract

Question 23

How is a colovesical fistula treated?

Answer 23

The problem can be corrected with surgery to remove the fistula and the affected part of the colon.

Question 24

What are the clinical signs suggesting a fistula in diverticular disease?

Answer 24

Passage of feces and gases (e.g., colo-vaginal fistula - leakage of feces through the vagina; colo-bladder fistula - pneumaturia, fecaluria).

Question 25

What are the categories of fistulas in diverticular disease?

Answer 25

Internal fistulas. External fistulas.

Question 26

Give examples of internal fistulas in diverticular disease.

Answer 26

Colo-enteric or colo-colonic fistulas.

Question 27

Give examples of external fistulas in diverticular disease.

Answer 27

Indirect through the cavitary visceral organs (vagina, uterus, bladder). Direct - colo-cutaneous purulent/stercoral fistulas.

Question 28

How are fistulas diagnosed?

Answer 28

Diagnostic - CT or Rx (e.g., air in the bladder).

Question 29

How is bleeding explained anatomically in diverticular disease?

Answer 29

Bleeding is explained anatomically by the proximity between the diverticular area and the right vessels of the colon, with secondary erosion and rupture. As the diverticulum increases, the vessel is separated only by a thin layer of muscle and can be susceptible to various aggressions.

Question 29

What type of digestive hemorrhage can diverticula cause?

Answer 29

Cause of lower digestive hemorrhage.

Question 30

What is the primary clinical manifestation of diverticular hemorrhage?

Answer 30

Rectorrhagia (rectal bleeding).

Question 31

What are the characteristics of the rectal bleeding in diverticular hemorrhage?

Answer 31

Sudden onset. Frequently abundant (massive bleeding), may require occasional blood transfusion.

Question 32

What other symptoms may accompany rectal bleeding in diverticular hemorrhage?

Answer 32

May be present abdominal cramps, tenesmus.

Question 33

What is necessary in the remaining cases of diverticular hemorrhage?

Answer 33

In the rest of the cases being necessary surgical intervention to perform hemostasis.

Question 34

What diagnostic explorations are used in diverticular hemorrhage?

Answer 34

Angiography and radioisotopes – scintigraphy with marked erythrocytes with Tc. Colonoscopy.

Question 35

What are the main principles of treatment for diverticular disease?

Answer 35

Induction of remission. Prevention of recurrences and complications.

Question 36

What are the therapeutic methods used in the treatment of diverticular disease?

Answer 36

Diet. Drug treatment. Endoscopic treatment. Surgical treatment.

Question 37

What is the treatment for asymptomatic diverticulosis?

Answer 37

Dietary regime supplemented with vegetable fiber. Bran from cereals – 3-5g/day with an increase to 15-20g/day.

Question 38

What is the dietary recommendation for uncomplicated symptomatic diverticulosis?

Answer 38

Diet enriched with vegetable fibers.

Question 39

How are patients with mild symptoms of uncomplicated symptomatic diverticulosis

Answer 39

Those with mild symptoms, without signs of peritonitis, without significant associated diseases, who can tolerate oral intake, can be treated at home with oral antibiotics (rifaximin)

Question 40

How are patients with severe symptoms of uncomplicated symptomatic diverticulosis treated?

Answer 40

Those with severe symptoms should be hospitalized for establishment: Digestive rest Parenteral hydration Administration of IV antibiotics

Question 41

What determines the medical management of acute diverticulitis?

Answer 41

The degree of the patient's symptoms. The severity of diverticular disease.

Question 42

In what situations are intravenous antibiotics and hospitalization required for diverticulitis?

Answer 42

Patients unable to tolerate an oral diet. Patients with severe comorbidities. Advanced age. Immunosuppression. Patients for whom oral antibiotics have been ineffective.

Question 43

How is uncomplicated diverticulitis typically treated?

Answer 43

Oral antibiotics (ciprofloxacin or metronidazole). A liquid diet.

Question 44

What factors determine the treatment of complicated diverticulitis?

Answer 44

The severity of illness. CT findings.

Question 45

What are the general goals of diverticulitis treatment?

Answer 45

Administration of antibiotics (covering Gram-negative bacteria and anaerobes). Putting the colon at rest. Influencing algic symptomatology (pain relief). Combating the infectious process. Hydroelectrolytic rebalancing.

Question 46

What is the treatment for mild forms of diverticulitis?

Answer 46

Ingestion of hydrosaccharate fluids.

Question 47

What is the treatment for severe forms of diverticulitis (with repeated vomiting and subocclusive syndrome)?

Answer 47

Nasogastric suction probe. Local ice bag. Administration of hydroelectrolytic and caloric needs IV.

Question 47

What is the preferred treatment for a stable patient with an approachable abscess, but without peritonitis or sepsis?

Answer 47

Percutaneous CT or US guided drainage. Antibiotic (AB) therapy. Total parenteral nutrition.

Question 48

What are the conditions for "cold" surgery in diverticulitis?

Answer 48

Resection of the affected segment, followed by intestinal anastomosis.

Question 49

How are small abscesses related to diverticulitis treated?

Answer 49

With intravenous antibiotic therapy and digestive rest.

Question 50

How are larger abscesses related to diverticulitis treated?

Answer 50

Tomographic/ultrasound-guided percutaneous drainage. Followed by selective single-stage surgery.

Question 50

What is the surgical approach for multiloculated or inaccessible abscesses, or those with peritoneal signs?

Answer 50

Surgery from the beginning, generally in two steps. Diversionary colostomy and Hartmann's pouch are performed. After healing, the colostomy is closed and reanastomosis is performed.

Question 50

What are the initial steps in managing diverticular hemorrhage?

Answer 50

Parenteral correction of hypovolemia. Parenteral correction of acute anemia.

Question 51

What is the initial diagnostic procedure performed when diverticular hemorrhage occurs?

Answer 51

Colonoscopic exploration to specify the location and origin of bleeding.

Question 52

What is the initial hemostatic intervention during colonoscopy for diverticular hemorrhage?

Answer 52

Hemostasis in situ by injection of Adrenaline.

Question 53

What is indicated in cases of persistent diverticular hemorrhage after initial colonoscopic hemostasis?

Answer 53

Angiography.

Question 54

What are the interventions performed during angiography for persistent diverticular hemorrhage?

Answer 54

Intraarterial administration of Vasopressin (hemostatic vasoconstrictor effect). Embolization with Gelfoam.

Question 55

What surgical procedure is indicated if continuous diverticular hemorrhage persists despite angiography?

Answer 55

Segmental colectomy.

Question 56

How does diet affect the risk of complications in symptomatic diverticulosis?

Answer 56

Enrichment of the diet with vegetable fibers decreases the risk towards an unfavorable evolution.

Question 57

What is a particular consideration regarding NSAIDs in elderly patients with diverticulosis?

Answer 57

Elderly patients should avoid NSAIDs as they increase the risk of perforation.

Question 58

What immunosuppressive treatment is preferred in kidney transplant patients with diverticulosis, and why?

Answer 58

Cyclosporine is preferred over corticotherapy because it has a lower risk of perforation.

Question 59

When is elective segmental resection surgery recommended for diverticulitis?

Answer 59

In young patients with recurrent episodes of diverticulitis or digestive hemorrhage.