Diverticulitis

Question 1

Define acute diverticulitis

Answer 1

Refers to inflammation of the diverticula (an outpouching of the colonic mucosa)

Question 2

Acute diverticulitis most commonly affects which part of the colon

Answer 2

Sigmoid colon

Question 3

Acute diverticulitis most commonly affects the sigmoid colon however right sided may be found in which patient group?

Answer 3

Those of Asian descent

Question 4

What are the two types of acute diverticulitis

Answer 4

Simple

Complicated

Question 5

What is simple diverticulitis

Answer 5

Diverticulitis without abscess or perforation

Question 6

What is Complicated diverticulitis

Answer 6

Diverticulitis with either abscess or perforation present

Question 7

Describe the pathophysiology of diverticula

Answer 7

An aging bowel naturally becomes weakened over time.

The movement of stool within the lumen will cause an increase in luminal pressure resulting in outpouchings of the mucosa through the weakened areas of bowel wall.

Question 8

Describe the pathophysiology of simple diverticulitis

Answer 8

An aging bowel naturally becomes weakened over time.

The movement of stool within the lumen will cause an increase in luminal pressure resulting in outpouchings of the mucosa through the weakened areas of bowel wall.

Bacteria can overgrow within the outpouchings, leading to inflammation of the diverticulum (simple diverticulitis)

Question 9

Describe the pathophysiology of complicated diverticulitis

Answer 9

An aging bowel naturally becomes weakened over time.

The movement of stool within the lumen will cause an increase in luminal pressure resulting in outpouchings of the mucosa through the weakened areas of bowel wall.

Bacteria can overgrow within the outpouchings, leading to inflammation of the diverticulum (simple diverticulitis)

These inflamed outpouchings can perforate leading to diffuse peritonitis (complicated diverticulitis)

Question 10

What are the two key risk factors for diverticulitis

Answer 10

Low fibre diet

Advancing age

Question 11

What are some of the clinical features of acute diverticulitis

Answer 11

• Acute abdominal pain
  
  • Left lower quadrant (may be in the right in some Asian patients)
  • Sharp
  • Worsened by movement
• Systemic upset
  
  • Pyrexia
  • Nausea/vomiting
  • Decreased appetite
• Signs of peritonism (if perforated)

Question 12

What are the two gold standard investigations for diverticulitis

Answer 12

Colonoscopy

CT abdomen and pelvis

Question 13

What blood tests will be raised in diverticulitis

Answer 13

Raised inflammatory markers e.g. CRP, WCC

Question 14

What is the name of the classification system for diverticulitis based on CT findings

Answer 14

Hinchey Classification

Question 15

What is the Hinchey Classification

Answer 15

Classification system for diverticulitis based on CT findings

Question 16

Most patients for diverticulitis can be managed conservatively.

What are the three components?

Answer 16

(1) Antibiotics (first line co-amoxiclav)
(2) IV fluids
(3) Analgesia

Question 17

Symptoms of diverticulitis typically improve within 2-3 days after the initiation

If the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms/complications, the patient requires admission to hospital for

Answer 17

IV antibiotics

Question 18

For patients unresponsive to antibiotics, or with complications (e.g. abscess, perforation, stricture or obstruction) surgical intervention may be required.

What are the two surgical interventions

Answer 18

Radiologically guided drainage of abscess or laparoscopic washout (under CT/ultrasound)

In more severe cases a Hartmann’s procedure may be required

Question 19

What is Hartmann’s procedure

Answer 19

The surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy. Anastomosis with reversal of colostomy may be possible at a later date

Question 20

What are the two most common complications of diverticular disease

Answer 20

(1) Stricture formation
(2) Fistula formation (colovesical; colovaginal)

Question 21

Name some of the common complications of diverticular disease

Answer 21

Stricture formation

Fistula formation (colovesical; colovaginal)

Recurrent diverticulitis

Diverticular bleeding

Abscess formation

Question 22

Strictures is a potential complication of diverticulitis.

How are they formed

Answer 22

Repeated episodes of diverticulitis and inflammation leads to scar tissue and stricture formation

This can result in large bowel obstruction

Question 23

Define fistula

Answer 23

Abnormal connection between two viscera

Question 24

What are the two types of fistula that can occur as a consequence of diverticulitis

Answer 24

Colovesical – connection between the bowel and bladder

Colovaginal – between the bowel and the vagina

Question 25

A diverticular abscess occurs in complicated diverticulitis.

How are diverticular abscess managed

Answer 25

Those that are around <5cm can generally be managed with conservatively with intravenous antibiotics

If the abscess is >5 cm radiological drainage is first-line treatment.