Diverticular Disease - Acute Diverticulitis Flashcards
(28 cards)
Define Diverticula
!Acquired sac-like herniation of the mucosa through the colonic wall
Define Diverticulosis
Presence of diverticula without inflammation!
Define Diverticular Disease
Give 3 specific symptoms
Symptomatic Diverticulosis => Presence of diverticula with symptoms AKA painful Diverticulitis
Altered bowel habit of Diarrhoea and constipation (mostly) => !Pellet Like Stool!
LIF pain/discomfort
Bloating
Perforation => sepsis
Recurrent UTI (colovesical fistula)
Where does the herniation typically occur?
What are the most common locations for Diverticulosis? State them in descending order of prevalence.
Herniation typically occurs between tenia coli as it is the entry point of nutrient arterioles (puncture through wall) => Weakest point
Sigmoid colon (most common)
Sigmoid colon + Descending colon
Sigmoid + Descending + Transverse
Pancolic
Cecal
What is meant by true and false diverticula?
Colonic diverticula are typically acquired and involve no muscle layers within the wall of the colon => False
Congenital diverticula typically involve all 3 muscle layers => true
Similar to true and false aneurysm
Give 6 RF for Diverticular disease. total = 9
Age (50% over 50)
Low fibre diet
Constipation a/w straining
Obesity
Physical inactivity
Smoking
Connective tissue disease: Ehler Danlos, Marfan’s (makes walls weaker as in AAA)
AD polycystic kidney disease (Risk factor for bleeding as well in stroke and SAH)
What is the pathogenesis of Diverticular disease from low fibre diet?
Low fibre diet => less stool volume => increased intraluminal pressure (think vasoconstriction) => muscle hypertrophy => herniation
What is the most common presentation of a patient with diverticulosis?
Diverticulosis = presence of diverticula without inflammation
The vast majority of patients are found incidentally during colonoscopy or barium enema => asymptomatic
What is the typical clinical presentation of simple acute diverticulitis?
1) Sx of acute abdomen (Sudden abdominal pain, nausea, vomiting, altered bowel habits, tenesmus, inability to empty bowels, fever/chills, bloating/swelling and tenderness/guarding, rebound guarding, tachycardia, tachypnea
2) LIF tenderness (rarely RIF)
3) Alternating/altered bowel habit: Constipation (mostly) and Diarrhoea with !Pellet-like stool!
4) Painless Spontaneous bleeding => Hematochezia
State the complications of Acute Diverticulitis or Diverticular disease as a whole
Obstruction/stricture formation
Abscess formation
Perforation/Peritonitis
Diverticular Fistula
A patient presents with simple acute diverticulitis with painless spontaneous bleeding. What is the significance of quantifying the volume?
Small volume = normal erosion of mural vessels by diverticulitis
Large volume = Rupture of a peri diverticular vessel
What is Rebound Tenderness a sign of?
Inflammation or irritation of the peritoneum => Peritonitis
What are the immediate investigations you will conduct in the setting of acute diverticulitis? (rationale where applicable)
Bloods: FBC (High WCC, majority neutrophils!!), U&E (disturbances), CRP, Coag, blood cultures (if systemically unwell), amylase
Imaging: !Erect CXR!
PFA for obstruction
CT angio/IV contrast CT abdomen to look for complications
LATER: Colonoscopy 6-8 weeks later to look for complications and malignancy
Although the vast majority of diverticula are found incidentally on colonoscopy or barium enema, why aren’t colonoscopies EVER done in the setting of acute diverticulitis?
To prevent causing bleeding and perforation. Instead we would schedule an colonoscopy 6-8 weeks later to look for possible complications and malignancies
What antibiotics would you prescribe to a patient with Acute diverticulitis?
IV Co-amox/Cefuroxime + Metronidazole
What is your management plan for a patient presenting to the hospital for a colonoscopy with an incidental finding of diverticula?
I will advise them to go for a fibre-rich diet, weight loss, stop smoking, increased exercise
I will prescribe probiotics and stool softeners
What is your full management of simple acute diverticulitis where a 45 year old patient is somewhat well with LIF tenderness, no rebound tenderness, and no bleeding PA. Include your conservative, medical, and surgical management (include indications). Im not asking for ABCDE management although you do it if needed obviously
Conservative: High fiber diet, Probiotics, Stool softener (+reduce RFs)
Medical: IV antibiotics Coamox/pip taz + Gent/Metronidazole
Surgical: US/CT guided Abscess drainage if presence of abscess >3cm
Laparoscopy +/- Washout escalated to Hartmann’s Procedure
Indications:Main -> not resolved on antibiotics, complications of diverticulitis in an uncomplicated presentation => peritonitis (Hinchey Classification III,IV), fistula, undrainable abscess.
Extra points! I will schedule a colonoscopy in 6-8 weeks to look for complications and malignancy as I would not want to risk perforation or bleeding in acute diverticulitis.
What is Hartmann’s procedure?
Proctosigmoidectomy, resecting the diseased segment (sigmoid), leaving the patient with a left-sided stoma
In acute diverticulitis how does obstruction occur as a complication?
How would you treat obstruction?
Stricture formation from chronic inflammation => luminal narrowing
Stricture tx: Endoscopic dilatation
In acute diverticulitis how do abscesses occur as a complication?
What are the types (locations) of abscesses seen in acute diverticulitis?
How would a patient present with an abscess?
What are your options for treating the abscess?
How would you treat a Perforated abscess?
Pathogenesis: Persistant inflammation + microperforations from microorganisms => pericolic abscess and may extend into paracolic space => paracolic abscess which may then extend to distant parts such as Pelvic and Retroperitoneal abscesses (these are the types)
Presentation: (very vague so no need for all) unresolving LIF pain + systemically unwell + features of sepsis + nausea vomiting.
Tx:
<3cm => conservative management => IV antibiotics of coamox + metronidazole
>3cm => US/CT guided drainage If undrainable => Laparoscopic washout +/- Laparotomy
Perforated abscess = Purulent Peritonitis => Laparoscopic washout +/- Laparotomy
How would you approach a patient presenting with acute diverticulitis WITH bleeding?
In all cases ABCDE, Hx and exam to determine if patient is stable or unstable
Stable => continue supportive care => fluids, group and hold, correct coag etc..
Unstable => Group and cross-match, CT angiography with vasopressin injection and transcatheter embolization
In acute diverticulitis, what are the two types of peritonitis?
Which is worse?
How would you treat each type?
Purulent Peritonitis due to perforation of an abscess (Hinchey III)
Tx: Laparoscopy and Washout +/- Laparotomy
Faeculent Peritonitis due to perforation of diverticular segment (Hinchey IV)
Tx: Hartmann’s procedure
A patient presents with the symptoms of acute diverticulitis but with pain on the right side. You suspect it might be appendicitis but your consultant shows you the pain is not severe enough and is not maximal on McBurney’s point. What is the explanation to this?
Cecal variant (5%) of diverticular disease. rare but exists
A patient presenting to the ED complaining of nausea, LIF pain, constipation, pebble-like stool and recurrent UTIs. What is your running diagnosis?
Acute Diverticulitis complicated by colovesical fistula
