Diverticular disease

Question 1

What is a diverticulum?

Answer 1

Sac-like protrusion of mucosa through muscular wall of the colon
Acquired or congenital.

Question 2

What is diverticulosis?

Answer 2

Presence of diverticulae outpouchings without Sx

Question 3

What is diverticular disease?

Answer 3

Diverticula cause Sx e.g. lower abdo pain, without inflammation or infection

Question 4

What is diverticulitis?

Answer 4

acute inflammation +/- infection of colonic diverticulae
Complicated or uncomplicated

Question 5

Distinguish between complicated and uncomplicated diverticulitis

Answer 5

‘Uncomplicated’: diverticular inflammation without Sx of acute abdomen, or signs of perforation or abscess formation.

‘Complicated: diverticulitis a/w complications, such as abscess, peritonitis, fistula, obstruction, or perforation.

Question 6

Describe the aetiology of diverticular disease

Answer 6

Low-fibre diet leads to loss of stool bulk.
Requires high colonic intraluminal pressures to propel the stool out
This leads to herniation of the mucosa + submucosa through muscle layers of the gut at weak points adjacent to penetrating vessels.

Question 7

At which site are diverticula most common?

Answer 7

Sigmoid + descending colon

Question 8

Describe the prevalence of right sided diverticula

Answer 8

15%
More common in Asians

Question 9

Describe the epidemiology of diverticular disease

Answer 9

VERY COMMON.
60% of HIC develop colonic diverticulae
Rare < 40y

Question 10

Give 4 risk factors for diverticular disease

Answer 10

Low fibre diet
Increasing age
Obesity
Genetics

Question 11

Describe the Hinchey Classification of Acute Diverticulitis

Answer 11

Ia: phlegmon: spreading diffuse inflammatory process with formation of purulent exudate
Ib + II: localised abscesses
III: perforation + purulent peritonitis
IV: faecal peritonitis: faeces in peritoneal cavity, due to LB perforation.

Question 12

How may diverticulosis present?

Answer 12

Asymptomatic (80-90%)
Commonly an incidental finding at colonoscopy

Question 13

What symptoms may arise from complications of diverticulosis?

Answer 13

Painless PR bleeding: Blood supply to colon is where outpouches occur so bleeds a lot

Question 14

What drug may provoke bleeding in diverticulosis?

Answer 14

NSAIDs

Question 15

What advice is given to those with diverticulosis?

Answer 15

Condition is asymptomatic + no specific Tx needed
Healthy balanced high fibre diet
Adequate fluid intake
Exercise, WL, smoking cessation reduce risk of diverticulitis

Question 16

Give 4 S/S of diverticular disease

Answer 16

Intermittent abdo pain in the left lower quadrant (may be triggered by eating + relieved by passage of stool or flatus).
Bloating
Rectal bleeding
Tenderness in the LLQ on palpation

Question 17

When should patients with diverticular disease be admitted?

Answer 17

if significant rectal bleeding (haemodynamically unstable), as urgent blood transfusion may be required.

Question 18

What advice is given to those with diverticular disease?

Answer 18

AVOID NSAIDs + Opioids (increased risk perforation)
High fibre diet
Safety net

Question 19

What medication may be offered to those with diverticular disease?

Answer 19

Bulk-forming laxatives if high-fibre diet not tolerated, or if constipation/ diarrhoea persist.

Paracetamol PRN

Antispasmodic (e.g. mebeverine) if abdominal cramping.

Question 20

Give an example of a bulk-forming laxative

Answer 20

Fybogel (ispaghula husk)
Methylcellulose

Question 21

Give 4 S/S of diverticulitis

Answer 21

Constant severe abdo pain (starts in hypogastrium before localizing to LLQ)
N+V
Fever.
CIBH + significant rectal bleeding or passage of mucus PR

Question 22

List 3 signs of diverticulitis

Answer 22

Tachycardia
Tender LIF +/- palpable mass /distension due to inflammation/ abscess
Possibly reduced bowel sounds

Question 23

What bloods are seen/ taken in diverticular disease/ diverticulitis?

Answer 23

Increased WCC
Increased CRP
Check clotting + cross-match if bleeding

Question 24

What investigation should be performed in the acute setting in diverticulitis?

Answer 24

Contrast CT: evidence of diverticular disease + complications
Colonic outpouchings, bowel wall thickening > 3 mm + peridiverticular mesenteric
fat stranding
(MRI if CT CI)

Question 25

Why should Barium enema or colonoscopy not be performed in the acute setting of diverticulitis?

Answer 25

High risk of perforation

Question 26

When may an abdominal x-ray be indicated in diverticulitis?

Answer 26

Suspected perforation or bowel obstruction OR As part of routine workup for acute abdominal pain

Question 27

What may be seen on AXR in complicated diverticulitis?

Answer 27

Bowel perforation: pneumoperitoneum Bowel obstruction: dilated bowel loops + multiple air-fluid levels

Question 28

What investigation is performed 6-8w after presentation with diverticulitis?

Answer 28

Colonoscopy / CT colonography to r/o IBD/ malignancy

Question 29

Describe management of complicated diverticulitis

Answer 29

IV Abx, fluids + analgesia Bowel rest +/- surgery

Question 30

In what setting should acute diverticulitis be managed?

Answer 30

MILD: oral Abx, liquid diet + analgesia SEVERE/ If Sx don't settle within 72h: Admit for IV Abx

Question 31

What antibiotics are used in diverticulitis?

Answer 31

Uncomplicated: Co-amoxiclav PO Complicated: Cefuroxime + Metronidazole IV

Question 32

When is surgery indicated in diverticulitis?

Answer 32

If acute complicated diverticulitis (e.g. with peritonitis + sepsis) If don't improve with medical Tx

Question 33

What surgical procedures may be performed in diverticulitis?

Answer 33

Percutaneous drainage of large abscesses. Laparoscopic lavage. Simple colostomy formation. Sigmoid resection with colostomy (Hartmann's procedure). Sigmoid resection with primary anastomosis +/- a diverting stoma.

Question 34

Describe the management of diverticulosis

Answer 34

Soluble high-fibre diet (20-30 g/day) Some drugs may prevent recurrent flares of diverticulitis (probiotics + anti-inflammatories e.g. mesalazine)

Question 35

Describe the management of a GI bleed in diverticular disease

Answer 35

PR bleeding usually managed conservatively with IV rehydration, Abx + blood transfusion if necessary Angiography + embolisation or surgery if severe

Question 36

When may elective surgery be considered for diverticulitis?

Answer 36

For recurrent complicated diverticulitis/ immunocompromised

Question 37

What is the prognosis of diverticular disease?

Answer 37

10-25% have one or more episodes of diverticulitis

Question 38

What occurs when diverticular are obstructed by thickened faeces

Answer 38

Bacterial overgrowth, toxin production + mucosal injury Can then lead to diverticulitis, perforation, pericolic phlegmon, abscess, ulceration + fistulation or stricture formation

Question 39

List 7 complications of divertiuclitis

Answer 39

Diverticulitis Haemorrhage Colovesical fistula Intra-abdominal abscess Perforation + faecal peritonitis Sepsis Intestinal obstruction

Question 40

List 3 signs of colovesical fistulation

Answer 40

Pneumaturia Faecaluria Pyuria