Diverticular disease

Question 1

Where do diverticula occur

Where are they most common

Answer 1

In GI tract but more common in sigmoid and descending colon

Question 2

What is a true diverticulum

Answer 2

Involving all layers of intestine

• serosa
• muscle
• submucosa
• mucosa

Question 3

What is a false diverticulum

Answer 3

Does not contain all layers

-Often mucosa pushed through muscle defect

Question 4

What is diverticulum pathology

Answer 4

Lack of dietary fibre leads to high intraluminal pressures

This allows the mucosa to herniate through the muscle layers of the gut at weak points close to penetrating vessels

Causes outputting of bowel wall

Question 5

Risk factors for diverticular disease

Answer 5

Western/ low fibre diet

Age
Male
Obesity
Connective tissue disorders
Smoking
Fam history
NSAID use

Question 6

What is Meckel’s diverticulum

Answer 6

Outpouching in the lower part of the intestine

It is a congenital abnormality

Question 7

Who is likely to have mocker’s diverticulum

Answer 7

<2yo

Question 8

Symptoms of mocker’s diverticulum

Answer 8

painless melaena
Followed by obstruction/intussusception

Can mimic appendicitis

Question 9

Meckel’s rule of 2

Answer 9

Affects 2% of pop
2 yo
2:1 M:F ratio
2 inches ling
2 feet proximal to ileocaecal valve
2 types of ectopic tissue (gastric/pancreatic)

Question 10

What is diverticulitis

Answer 10

bacterial overgrowth which causes inflammation of diverticulum

Question 11

Complications of diverticulitis

Answer 11

Perforation of the bowel and fistula formation

Question 12

Who has an increased risk of complications and recurrence of diverticulitis

Answer 12

Younger pts

Question 13

Presentation of diverticulosis

Answer 13

asymptomatic

Question 14

Presentation of diverticular disease

Answer 14

Colicky Lowe abdo pain (often left sided)

relieved by defecation or flatus and exacerbated by eating

Altered bowel habit. Associated nausea, bloating and flatulence

Question 15

Presentation of divet=rticulitis

Answer 15

acute onset.
Sharp, LIF pain
Worsened by movement with localised tenderness

Loose stools

Symptomatically unwell- nausea, fever, tachycardia, N+V

Question 16

Presentation of diverticular bleed

Answer 16

Large scale painless bleed

Dark red blood

Severe haemorrhage in 3-5% of pts

Question 17

Differentials for diverticular disease

Answer 17

IBD
Bowel cancer 
ISchaemic colitis
Gyno causes
renal stones
IBS
Coeliac disease

Question 18

Bedside exams for diverticular disease

Answer 18

General obs + PR exam
Abdo exam
Urine dip to exclude urinary cause
(+/- Faecal calprotectin- can be raised in diverticulosis or IBD or IBS)

Question 19

Bloods for diverticular disease

Answer 19

FBC
U&E
LFT
CRP

should all be normal

Question 20

specialist imaging for diverticular disease

Answer 20

Sigmoidoscopy or colonoscopy

CT colonogram if pt not fit enough for colonoscopy procedure

Question 21

Flexi sigmoidoscopy vs colonoscopy

Answer 21

Colonoscopy looks at entire large bowel

Sigmoidoscopy looks up to half of descending colon

Question 22

Bedside exams for diverticulitis

Answer 22

GEneral obs (increased HR, febrile, hypotension)

Abdo exam- palpable mass +/- localised peritonism

Urine dip to exclude urinary cause

+/- faecal calprotectin

Question 23

Bloods to do for investigating diverticulitis

Answer 23

FBC
U&E
CRP

-Increased WCC and CRP

Blood cultures

VBG/ABG
-Increased lactate

Question 24

imaging for Diverticulitis

Answer 24

Erect CXR for pneumoperitoneum indicating perforation

AXR to look for bowel obstruction

USS abdomen/pelvis
CT abdomen/pelvis

Question 25

What to avoid when investigating diverticulitis

Answer 25

Endoscopic procedures due to risk of perforation

Question 26

Bedside investigations for diverticular bleed

Answer 26

General obs -Hypotension, Increased HR and RR Abdo exam- palpable mass + peritonitis abdomen Urinary dip +e faecal calprotectin

Question 27

Bloods for diverticular bleed

Answer 27

FBC U&E CRP -Increased WCC, Increased CRP and decreased HB VBG/ABG -increased lactate Group and save and crossmatch -For blood transfusion Blood cultures

Question 28

Imaging for Diverticular bleed

Answer 28

Erect CXR for pneumoperitoneum indicating perforation AXR to look for bowel obstruction CT abdomen/pelvis Urgent colonoscopy to find source of bleeding and treat if indicated

Question 29

MAnagemt of diverticulosis

Answer 29

No follow up if asymptomatic Propylactic benefit of high fibre diet

Question 30

Mnagemtn of diverticular disease

Answer 30

Conservative - - Encourage PO fluids - High fibre diet - Weight loss - Smoking cessation Medical - Paracetamol - If high fibre diet not effective then bulk forming laxatives

Question 31

Management of diverticulitis

Answer 31

Conservative - Encourage PO fluids - Clear fluids only, reintroducing solids as Symptoms improve over 2-3 days Medical - Paracetamol - Broad spectrum antibiotics IV - IV fluids - Blood transfusion if haemorrhage Surgical - for acute complicated diverticulitis (perforation) surgical management may be indicated - Hartmann's procedure or sigmoid resection with primary anastomoses are most likely

Question 32

Complications of diverticulitis

Answer 32

Pericolic abscess (collection of pus within large bowel wall) Fistulas (abnormal connection between two epithelialise surfaces) Perforation ``` Bowel obstruction (small bowel obstruction due to inflammation) -If there is a stricture formation, warrants further investigations) ```

Question 33

Presentation and treatment of pericolic abscess

Answer 33

Swinging fevers, mass OE and generally unwell If small, can be treated with antibiotics Normal need USS or CT guided drainage

Question 34

Presentation and treatment of fistulas

Answer 34

Colovesical fistula- connection between colon and bladder Colovaginal fistula- connection between colon and vagina Colovesical fistulae present with pneumoturia (bubbles in urine), faecal matter in urine and recurrent UTIs colovaginal fistulae present with faecal matter in vagina and recurrent vaginal infections Surgical intervention usually indicated

Question 35

Symptoms and treatment of perforation

Answer 35

Generalised peritonitis Ileus +/- shock Surgical emergency

Question 36

Symptoms and treatment of bowel obstruction

Answer 36

Abdo pain and distension N&V and absolute constipation If SBO during acute episode, may resolve spontaneously If ongoing, may need stenting or surgery