Diverticular disease

Question 1

What is diverticulosis?

1 - abnormal small bowel walls
2 - abnormal gastric walls
3 - out-pouching of a hollow tube
4 - out-pouching of intestines through abdominal wall

Answer 1

3 - out-pouching of a hollow tube

• essentially a protrusion of the mucosa through the muscles of the bowel

Question 2

Re-arrange the order of how diverticulum are formed?

1 - mucosa herniates through weakness in wall, normally where taeniae coli are located
2 - hypersegmentation occurs where peristalsis from 2 opposing segments of colon contract at the same time
3 - increased intraluminal pressure
4 - colonic circular muscle is thickened due to increased elastic tissue between muscle fibres
5 - 2 segments contracting send peristalsis waves towards each other

Answer 2

1 - colonic circular muscle is thickened due to increased elastic tissue between muscle fibres
2 - hypersegmentation occurs where peristalsis from 2 opposing segments of colon contract at the same time
3 - 2 segments contracting send peristalsis waves towards each other
4 - increased intraluminal pressure
5 - mucosa herniates through weakness in wall, normally where taeniae coli are located

Question 3

In diverticulosis, which layers of the bowel are included in a true diverticulosis?

1 - serosa
2 - mucosa
3 - submucosa
4 - muscle
5 - all of the above

Answer 3

5 - all of the above

Question 4

In diverticulosis, which layers of the bowel are included in a false (pseudo) diverticulosis?

1 - serosa
2 - mucosa
3 - submucosa
4 - muscle
5 - all of the above

Answer 4

2 - mucosa
3 - submucosa

• these are the most common type of diverticulosis in colon

Question 5

What determines diverticulosis from diverticular disease?

1 - inflammation
2 - blood in stool
3 - symptoms associated with diverticula
4 - weight loss

Answer 5

3 - symptoms associated with diverticulosis

Question 6

What common gastrointestinal symptom is often associated with diverticular disease?

1 - diarrhoea
2 - constipation
3 - blood in stool
4 - weight loss

Answer 6

2 - constipation

• associated with low dietary fibre
• diverticular disease is the most significant risk factor for constipation

Question 7

Is diverticular disease more common in the developed western world or the rest of the world?

Answer 7

• western world, due to low dietary fibre and processed foods

Question 8

What is the the most common location in the bowel for diverticular disease?

1 - ileum
2 - ascending colon
3 - sigmoid colon
4 - descending colon

Answer 8

3 - sigmoid colon

• has highest intra-luminal pressure

Question 9

What age does 50% of diverticular disease occur in?

1 - >20 y/o
2 - >50 y/o
3 - >70 y/o
4 - >90 y/o

Answer 9

2 - >50 y/o

• can be reported as >60 y/o

Question 10

Diverticular disease is an out-pouching of the mucosal pouches beyond the musculature wall of the bowel with symptoms associated. What % of patients with diverticular disease DO present with symptoms?

1 - 100%
2 - 90%
3 - 50%
4 - 10%

Answer 10

4 - 10%

Question 11

Diverticular disease is an out-pouching of the mucosal pouches beyond the musculature wall of the bowel with symptoms associated. What is diverticulitis?

1 - inflammation of the diverticula
2 - infection of the diverticula
3 - pus forming diverticula
4 - blocked diverticula

Answer 11

1 - inflammation of the diverticulosis

Question 12

Diverticular disease is an out-pouching of the mucosal pouches beyond the musculature wall of the bowel with symptoms associated. What is diverticular colitis?

1 - inflammation of the diverticula
2 - infection of the diverticula
3 - cresenteric inflammation on folds of an area of diverticulosis
4 - blocked diverticula

Answer 12

3 - cresenteric inflammation on folds of an area of diverticulosis

Question 13

What is the most common cause of diverticulitis?

1 - TB
2 - stool blocking the diverticula
3 - E.coli infection
4 - fistula formation

Answer 13

2 - stool blocking the diverticula

Question 14

How is diverticular disease most commonly identified?

1 - following CT scans
2 - incidental finding
3 - during colonoscopy
4 - X-ray

Answer 14

2 - incidental finding

• especially as only 10% of patients present with symptoms

Question 15

If a patient presents with an acute abdomen that is due to acute diverticulitis, where is the most common location for pain?

1 - LIF
2 - RIF
3 - parasternal border
4 - left paracolic gutter

Answer 15

1 - LIF

• but can be anywhere, but most common is LIF as most common in sigmoid colon
• patient is systematically unwell

Question 16

If a patient presents with an acute abdomen due to a perforated diverticular. Which of the following is NOT a common presentation of this?

1 - nausea and vomiting.
2 - fever.
3 - abdominal tenderness
4 - rebound tenderness
5 - constipation
6 - mass in LIF

Answer 16

6 - mass in LIF

• diverticular can lead to a mass, but most unlikley

Question 17

In a patient with diverticular disease, is a diverticular bleed dangerous?

Answer 17

• no
• usually self limiting

Question 18

Stool blocking the diverticula is the most common cause of diverticulitis. Which of the following does this NOT tend to lead to?

1 - fistula to adjacent organs
2 - bowel necrosis and perforation
3 - bowel obstruction
4 - abscess formation
5 - haemorrhage

Answer 18

5 - haemorrhage

• obstructions caused by stricture are very difficult to distinguish from malignancy

Question 19

Which of the following is NOT a common presentation of acute diverticulitis?

1 - nausea and vomiting
2 - blood in urine
3 - odd bowel habits
4 - sign of infection or sepsis
5 - urinary habits change/dysuria
6 - peritonitis

Answer 19

2 - blood in urine

Question 20

What is the conservative medical management of a patient presenting with uncomplicated symptomatic disease due to diverticulitis?

1 - antibiotics
2 - fluids
3 - soluble/insoluble diet
4 - analgesia and antibiotics

Answer 20

3 - soluble/insoluble diet

Question 21

Which of the following is NOT a common differential of diverticulitis?

1 - IBS
2 - colorectal cancer
3 - acute appendicitis
4 - gastritis
5 - infectious/ischaemic colitis
6 - ovarian/uterus issues
7 - cystitis (bladder inflammation)
8 - nephrolithiasis (kidney stones)

Answer 21

4 - gastritis

Question 22

What 2 blood markers are commonly used that can help identify if a patient has diverticulitis?

1 - WBC and CRP
2 - WBC and RBC
3 - CRP and RBC
4 - CRP and eosinophils

Answer 22

1 - WBC and CRP

Question 23

Although preferentially used for patients who are older, what is commonly the first imaging modality used to try and diagnose diverticulitis?

1 - ultrasound
2 - MRI
3 - CT scan
4 - X-ray

Answer 23

3 - CT scan

• CT colongraphy is best

Question 24

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. Of the 4 stages which can be treated medically with just antibiotics alone?

1 - stage 1
2 - stage 2
3 - stage 3
4 - stage 4

Answer 24

1 - stage 1

Question 25

What is an abscess? 1 - sac filled with fluid or other material lined by epithelial cells 2 - fluid filled area lined by granulation tissue 3 - pus filled collection that can be lined by various cell types 4 - blind ended tract

Answer 25

3 - pus filled collection that can be lined by various cell types

Question 26

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. What is the common cause for stage 1 diverticulitis to present? 1 - stricture forms 2 - pericolic or mesenteric abscess forms 3 - fistula forms 4 - spasm of large bowels

Answer 26

2 - pericolic or mesenteric abscess forms - pericolic refers to surrounding of the colon - <4cm in size - mortality is <5%

Question 27

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. What is the common cause for stage 2 diverticulitis to present? 1 - stricture forms 2 - small pericolic or mesenteric abscess forms 3 - fistula forms 4 - large pelvic abscess

Answer 27

4 - large pelvic abscess - mortality is <5%

Question 28

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. Of the 4 stages which can be treated medically with antibiotics and percutaneously drainage of the abscess? 1 - stage 1 2 - stage 2 3 - stage 3 4 - stage 4

Answer 28

2 - stage 2 - drainage may require laparoscopy

Question 29

In a patient with stage 1 or 2 diverticulitis, which is associated , called the Hinchey classification, what is the best way to diagnose the patient? 1 - colonoscopy 2 - X-ray 3 - sigmoidoscopy 4 - CT with contrast

Answer 29

4 - CT with contrast - generally barium enema

Question 30

In a patient who is being treated medically with a conservative approach for a stage 1 or 2 acute presentation of diverticulitis, which 2 antibiotics are generally prescribed? 1 - Doxycycline 2 - Clarithromycin 3 - Ciprofloxacin 4 - Metronidazole

Answer 30

3 - Ciprofloxacin 4 - Metronidazole

Question 31

Patients with signs of systemic upset (fevers, tachycardia), significant abdominal pain or co-morbidity require bowel rest, intravenous fluids and intravenous antibiotic therapy. Why does the bowel require rest? 1 - allows recovery 2 - antibiotics are most affective during rest 3 - immunity is better at rest 4 - inflammation can be worse with rest

Answer 31

1 - allows recovery - antibiotics and fluid will relieve workload on colon allowing some recovery and even clearing of symptoms. Food can prolong and exacerbate symptoms

Question 32

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. What is the common cause for stage 3 diverticulitis to present? 1 - rupture with faecal peritonitis 2 - small pericolic or mesenteric abscess forms 3 - small perforation causing gaseous and purulent peritonitis 4 - large pelvic abscess

Answer 32

3 - small perforation causing gaseous and purulent peritonitis - mortality is 13%

Question 33

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. The diverticulum can perforate from a pin hole size to >1cm. This can lead to gaseous and faecal contents causing peritonitis.Which 2 imaging modalities can detect this? 1 - ultrasound 2 - CT scan 3 - X-ray 4 - MRI

Answer 33

2 - CT scan 3 - X-ray - scan must be erect - we can see pneumoperitoneum

Question 34

How can stage 3 small perforations be managed? 1 - bowel rest 2 - antibiotics 3 - percutaneous drain 4 - all of the above

Answer 34

4 - all of the above - large stage 4 perforations need urgent surgery though

Question 35

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. What is the common cause for stage 4 diverticulitis to present? 1 - rupture with faecal peritonitis 2 - small pericolic or mesenteric abscess forms 3 - small perforation causing gaseous and purulent peritonitis 4 - large pelvic abscess

Answer 35

1 - rupture with faecal peritonitis - mortality is 43%

Question 36

There are 4 stages of diverticulitis, called the Hinchey classification used to describe perforations of the colon due to diverticulitis. Of the 4 stages which needs to be treated surgically? 1 - stage 1 2 - stage 2 3 - stage 3 4 - stage 4

Answer 36

3 - stage 3 4 - stage 4

Question 37

The Hartmann’s procedure is often used in a patient with acute diverticulitis at stage 3 or 4. What is this procedure? 1 - removal of whole colon and colostomy 2 - removal of whole sigmoid colon and colostomy 3 - removal of part of colon affected and colostomy 4 - removal of rectum and colostomy

Answer 37

3 - removal of part of colon affected and colostomy - can be reversed at a later stage and turned into an anastomosis

Question 38

Why are sigmoidoscopy and colonoscopy not performed during acute diverticulitis presentation? 1 - can be painful 2 - can cause infection 3 - increased risk of perforation 4 - cannot see anything

Answer 38

3 - increased risk of perforation

Question 39

In patients who are discharged following surgical treatment, what % are likely to have a reoccurrence? 1 - 1% 2 - 15% 3 - 25% 4 - 33%

Answer 39

4 - 33% - of this 33% will have 1 further occurrence

Question 40

Which of the following is NOT a differential for diverticulitis? 1 - IBS 2 - Colorectal cancer 3 - Toxic mega colon 4 - Acute appendicitis 5 - Infection/Ischaemic colitis 6 - Ovarian abscess/cyst 7 - Cystitis 8 - Nephrolithiasis

Answer 40

3 - Toxic mega colon

Question 41

Chronic diverticular occurs in patients with diverticular disease who have multiple acute presentations of their diverticular. How common is this? 1 - 0.1-0.2% 2 - 1-2% 3 - 10-20% 4 - 20-40%

Answer 41

2 - 1-2%

Question 42

What are the 2 main problems that patients with chronic diverticular (patients with diverticular disease who have multiple acute presentations of their diverticular)? 1 - colorectal cancer 2 - diverticular fistulae 3 - meta-toxic colon 4 - chronic strictures

Answer 42

2 - diverticular fistulae 4 - chronic strictures - both can lead to a larger bowel obstruction

Question 43

The 2 main problems that patients with chronic diverticular (patients with diverticular disease who have multiple acute presentations of their diverticular) have are diverticular fistulae and chronic strictures. Which of the following are the most likely form of fistula to form? 1 - colo-vesicle 2 - colo-colonic 3 - colo-uterine 4 - colo-vaginal

Answer 43

1 - colo-vesicle - cause UTIs, pneumaturia (air in urine) and stool in urine 4 - colo-vaginal - common in women who have had hysterectomy - UTI and faecal discharge in vagina

Question 44

In a patient who has developed a diverticular fistula due to their chronic diverticular, which of the following is NOT a common part of patients management? 1 - conservative (antibiotics and fluids) 2 - Hartman's procedure 3 - defunctioning stoma 4 - complete colectomy

Answer 44

4 - complete colectomy

Question 45

In a patient who has developed chronic diverticular and decides to have elective surgery, what % will have recurrent persistent symptoms after? 1 - 0.25% 2 - 2.5% 3 - 25% 4 - 50%

Answer 45

3 - 25% - stomas are high in elderly or complex surgeries

Question 46

In a patient who has developed chronic diverticular, following treatment, what condition are the following symptoms most commonly associated with? 1 - colorectal cancer 2 - IBS 3 - IBD 4 - appendicitis

Answer 46

2 - IBS