Diverticular Disease

Question 1

what is diverticulosis

Answer 1

presence of diverticulae, outpouchings of the mucosal and submucosal colon through the muscular wall of the large bowel

Question 2

what is diverticular disease

Answer 2

diverticulosis associated with complications. for example haemorrhage, infection or fistulae

Question 3

what is diverticulitis

Answer 3

acute inflammation and infection of the colonic diverticulae

Question 4

what is the Hinchley classification of diverticulitis

Answer 4

Ia- phlegmons
Ib and II- localised abscesses
III- perforated abscesses
IV- faecal peritonitis

Question 5

what is a phlegmon and what is the difference with an abscess

Answer 5

phlegm’s are purulent inflammatory processes characterised by tissue necrosis

abscesses are localised whereas phlegmons can keep spreading along the muscular fibre, unbounded

Question 6

aetiology of diverticular disease

Answer 6

low-fibre diet leads to loss of stool bulk, this leads to high colonic intraluminal pressure to propel stool which causes herniation of the colonic submucosa and mucosa through the muscularis

Question 7

summarise pathogenesis of diverticular disease

Answer 7

diverticulae are most likely to be found on the sigmoid colon and descending (LEFT SIDES) but can also be found on the right
diverticulae will not be found in the rectum

Question 8

what sites are diverticulae usually found at

Answer 8

sites of nutrient artery perforation

Question 9

what may diverticular obstruction lead to

Answer 9

obstruction by thickened faeces can lead to bacterial overgrowth, toxin production and mucosal injury. this can then lead to diverticulitis, perforation, ulceration or stricture formation

Question 10

epidemiology

Answer 10

very common,
rare below the age of 40,
60% of people living in industrialised areas will develop diverticular disease

Question 11

risk factors for diverticular disease

Answer 11

age above 50,
low fibre diet,
diet rich in meat, sugar and salt,
BMI above 30 (obesity)

Question 12

how does diverticular disease present

Answer 12

often asymptomatic (80-90%)
LLQ pain, guarding and tenderness
bloating
constipation

Question 13

what symptoms can complications lead to

Answer 13

PR bleeding, diverticulitis (acute inflammation associated with LIF pain, fever), diverticular fistulation (faecaluria, pneumaturia, UTI)

Question 14

why can there never be urine in the faeces but can have faeces in the urine

Answer 14

bladder has a lower pressure than the rectum so down a pressure gradient, faeces can pass into urine

Question 15

signs of diverticular disease on physical examination

Answer 15

diverticulitis will show a tender abdomen and signs of general/local peritonitis if a divertulae has perforated

Question 16

what investigations will be carried out

Answer 16

bloods, barium enema and flexible sigmoidoscopy and colonoscopy

Question 17

what bloods will be ordered and what will you expect to see

Answer 17

high WCC and CRP. check for clotting and cross-match if bleeding

Question 18

why will a barium enema not be done in an acute setting

Answer 18

hazardous and increases the risk of perforation and therefore will not be performed in an acute setting

Question 19

why is a flexible sigmoidoscopy and colonoscopy significant/ relevant

Answer 19

diverticulae can be seen and therefore other pathology such as tumours and polyps can be excluded

Question 20

in an acute setting what investigation will be done

Answer 20

CT as it shows evidence for diverticular disease as well as complications

Question 21

management plan of diverticular disease if patient is asymptomatic

Answer 21

high fibre diet (20-30g per day), probiotics and inflammatories to prevent diverticulitis flare ups

Question 22

management of GI bleeds

Answer 22

conservative management with IV fluids to rehydrate, antibiotics and if necessary, a blood transfusion should be performed. if severe angiography and embolisation or surgery

Question 23

what is angiography with embolisation

Answer 23

method to manage and treat GI bleeds. its a minimally invasive procedure to block blood vessels in an aim to stop bleeding

Question 24

management of diverticulitis

Answer 24

IV ABx, IV fluids, bowel rest, abscessed may be drained using radiologically sited drains

Question 25

when is surgery available to those with diverticular disease

Answer 25

if the patients have recurrent attacks (flare ups) or complications such as peritonitis or perforation

Question 26

what surgery will be done

Answer 26

1. laparoscopic (keyhole) drainage, peritoneal lavage and drain placement
2. open surgery (Hartmanns procedure or one step resection) and anastomosis

Question 27

what is anastomosis and what is the risks involved

Answer 27

surgical connection between two structures. It usually means a connection that is created between tubular structures, such as blood vessels or loops of intestine.

carries a risk of leakage

Question 28

possible complications of diverticular disease

Answer 28

perforation, faecal peritonitis, pericoli abscess, diverticulitis, colonic obstruction, fistula formation (bladder vagina and small bowel) and haemorrhages

Question 29

what symptoms are obstructions consistent with

Answer 29

colicky pain and change in bowel habit.

perforations result in SUDDEN acute onset of persistent pain

Question 30

prognosis

Answer 30

10-25% will have one or more episodes of diverticulitis