GI: Diverticular Disease

Question 1

What is a diverticulum?

Answer 1

Herniation of mucosa through thickened colonic muscle (typically 5-10mm diameter, but can exceed 2cm).

Question 2

What is the difference between true and false diverticula?

Answer 2

True diverticula (uncommon): contain all layers of wall, e.g. Meckel’s diverticulum

False diverticula (common): don’t contain all layers - typically mucosa pushed through defect in muscular layer, e.g. colonic diverticulum

Question 3

Where do diverticula most commonly occur?

Answer 3

Can occur throughout GI tract but most commonly seen in sigmoid and descending colon.

Question 4

What is the difference between diverticulosis, diverticular disease and diverticulitis?

Answer 4

Diverticulosis: presence of asymptomatic diverticula

Diverticular disease: diverticula associated with symptoms

Diverticulitis: diverticular inflammation (fever, tachycardia) +/- localised symptoms and signs

Question 5

Why to diverticula occur?

Answer 5

Movement of stool causing increased luminal pressure in aging bowel naturally weakened in certain areas… outpouching of mucosa… accumulation of bowel content (inc. bacteria)

Question 6

Name 3 risk factors for diverticular formation. In which Pts is frequency of complicated disease increased?

Answer 6

Risk factors:

• age >50yo
• low dietary fibre
• obesity

Complicated disease more likely in pts who smoke, use NSAIDs and paracetamol.

Question 7

Describe the presentation of simple diverticular disease.

Answer 7

LLQ pain (may be RLQ in asian Pts) - typically colicky

+/- nausea
+/- change in bowel habit

Question 8

Describe the presentation of diverticulitis.

Answer 8

Symptoms:
- LLF pain (may be RLQ in asian Pts) - can be intermittent or constant
- fever
- PR bleeding - usually sudden and painless
+/- anorexia, nausea and vomiting
+/- change in bowel habits

Signs:

• tachycardia
• localised tenderness

Question 9

Which investigations would you perform on someone with suspected diverticular disease/diverticulitis?

Answer 9

1/ Bloods

• normal in simple diverticular disease
• diverticulitis: increased WCC, increased platelets, anaemia, increased CRP

2/ Imaging

• flexible sigmoidoscopy: initial approach in diverticular disease (but not diverticulitis due to risk of perforation)
• CT abdo-pelvis – accurate in diagnosing diverticular disease and any complications (e.g. abscess), and assessing for DDx
• erect CXR is suspected perforation

Question 10

How would you manage a Pt with diverticular disease?

Answer 10

1. advise high fibre diet and high fluid intake
2. bulk-forming laxatives, e.g. ispaghula husk (Fybogel)
3. paracetamol for pain management

Question 11

How would you manage a Pt with diverticulitis?

Answer 11

1. ABCDE

Conservative:

2. IV fluids
3. broad-spectrum IV antibiotics
4. bowel rest (clear fluids only)
5. analgesia
6. IV blood if significant PR haemorrhage

Surgical (if perforation + peritonitis, sepsis or failure to improve):

7. laparoscopic lavage (if abscess) OR
8. bowel resection - primary anastamosis or Hartmann’s procedure (end colostomy and closure of rectal stump)

Question 12

Describe 4 possible complications of diverticular disease.

Answer 12

1. abscess - pericolic or more extensive.
2. bowel obstruction - secondary to stricture formation.
3. fistula formation - colovesical or colovaginal
4. perforation

Question 13

How would a colovesical fistula present?

Answer 13

• pneumouria
• faecaluria
• recurrent UTIs