Diverticular disease Flashcards
What is diverticular disease?
Defined as having presence of diverticula (plural diverticulum).
Diverticula are pouches protruding/sticking outwards from the large intestine wall.
They’re also described as small mucosal herniations protruding through intestinal layers and smooth muscle.
Diverticular disease is when the patient becomes symptomatic to the presence of diverticula.
What is diverticulosis?
It is a condition where we have uninflammed diverticula.
Simply the presence of diverticula in the large intestine of a patient.
- Usually asymptomatic
What is diverticulitis?
Condition where one or more inflamed/infected diverticula present.
What causes diverticular disease? (aetiology)
Causative agents are UNKNOWN
However diverticular disease is associated with:
- Increased intraluminal (the lumen is the opening inside the large intestine which the waste material is passing) pressure and weakening of muscle wall thought to be PRIMARY cause
- Abnormal colonic motility (e.g. IBS or use of opioids)
- Defective muscular structure
- Changes in collagen structure e.g. in aging where elasticity is lost
Other factors:
1. Genetics
- Left-sided diverticula predominate in the west
- Right-sided predominant in Asians
- Dietary factors
- Associated with a low fibre diet and constipation
- Associated with obesity
What is the pathogenesis of diverticular disease?
Colonic muscular hypERtrophy results in narrowing of lumen and formation of small chamber with high pressure and subsequent diverticula.
So the formation of diverticula takes place at an area of weakness at the lining of the large intestine. These areas tend to be where we have cappillaries.
DIVERTICULITIS:
- Faecal material or undigested food collect in the diverticula and cause obstruction
- Mucus secretion and normal bacterial overgrowth leads to distension of diverticula
- Results in vascular compromise and perforations (holes)
- Increase in intraluminal pressure and stuck food particles may also damage diverticula wall, resulting in inflammation and necrosis and perforation
- Recurrent attacks lead to scar tissue formation and further lumen narrowing
How is diverticulosis managed?
- Asymptomatic- hence no need for routine follow ups
- Maintain healthy balanced diet, high in fibre
- Maintain adequate fluid intake to avoid dehydration
- If overweight, advise about benefits of weight loss, exercise and also smoking cessation to prevent progression
- If constipated -> offer bulk forming laxative
What happens when you have diverticular disease?
There’s intermittent pain in lower left quadrant (with constipation, diarrhoea, rectal bleeds)
Abdominal pain is worsened by eating, relieved by passing stool or wind
Flatulence (gas)
Lower left quadrant tenderness on palpation
Asian populations symptoms may present right sided.
Symptoms can overlap with other conditions such as IBS
No systemic symptoms
How is diverticular disease managed?
- High fibre diet
- Bran supplements/Bulk-forming laxatives
- Lifestyle advice as per diverticulosis
- Anti-spasmodics when colic e.g. Alverine, Mebeverine, Peppermint oil etc
- AVOID NSAIDs
- Anti-motility drugs to slow transit time e.g. codeine and loperamide should NOT be used
- Risk of diverticular perforation (holes)
What happens when you have Diverticulitus?
Constant lower left abdominal pain with:
- Fever
- Sudden bowel change
- Blood/mucus in stools
- Lower left quadrant tenderness
- Palpable abdominal mass/distention
- Malaise
- Nausea and vominting
- Increased WBC
- If bleeding occurs -> increased platelets
- Anaemia
- Increased CRP
How is diverticulitis managed?
Refer for hospital assessment if:
- Patient is over 65yrs
- Co-morbidities or immunosuppressed
- Can’t take oral antibiotics at home
- Dehydrate / at risk, can rehydrate sufficiently from home
- Uncontrollable abdominal pain + signs of complicated acute diverticulitis
What are the signs of complicated acute diverticulitis?
- Intra-abdominal abscess (mass on examination-painful collection of puss)
- Diverticular haemorrhage
- Peritonitis (rigidity/guarding upon examination)
- Stricture (reduce GI motility, constipation, cramping)
- Fistula formation (Faecaluria, pneumaturia (lack of movement of stool or wind), passing faeces through vagina)
- Intestinal obstruction (cramping, absolute constipation, distension)
- Sepsis
How is diverticulitis managed?
If Acute + Systemically Unwell (but doesn’t need admission):
- Co-amoxiclav 500/125 TDS x 5 days (Cefalexin if penicillin allergy) + Metronidazole 400mg TDS x 5 days
OR - Trimethoprim 200mg BD x 5 days + Metronidazole 400mg TDS x 5 days
If Acute + Systemically Well: (needs hospital admission)
- Consider NO antibiotic strategy
- Analgesia e.g. Paracetamol (avoid NSAIDs/opiods)
- Re-present if symptoms worsen
