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Diverticular disease/diverticulitis
Diverticular disease/diverticulitis

Diverticular disease/diverticulitis

Some definitions first:

  • Diverticulosis – the presence of diverticula (asymptomatic, incidental on imaging)
  • Diverticular disease – symptoms arising from the diverticula
  • Diverticulitis – inflammation of the diverticula
  • Diverticular bleed – where the diverticulum erodes into a vessel and causes a large volume painless bleed.
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DIVERTICULAR DISEASE

🏘 Epidemiology

Age and low-fibre diet are two main risk factors for diverticulosis. Obesity and sedentary lifestyle may contribute too.

It is asymptomatic, but once symptomatic it is referred to as diverticular disease.

Diverticulosis is present in almost 50% of adults aged 50+ and 70% of those 80+. However, only 25% are symptomatic. It is almost always in the sigmoid colon, but interestingly in Asian patients

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It occurs when the the colonic mucosa herniates through the muscular wall of the colon. It normally happens within the taenia coli as vessels pierce the muscle at this site and therefore it is weaker. The rectum lacks taenia coli and often does not suffer this pathology as a result.

😷 Symptoms

  1. Altered bowel habit
  2. Rectal bleeding
  3. Abdominal pain - colicky and relieved by defecation sometimes.

It typically is not an issue, however, the complications that may arise from it are more worrisome and that is why surgery may be indicated in some cases.

🚨  Complications

  • Diverticulitis (we will discuss this shortly)
  • Haemorrhage
  • Fistula formation
  • Phlegmon development ➡️
  • Abscess development
  • Perforation (with faecal peritonitis)

🔍 Investigations

Colonoscopy CT cologram or barium enema may be used to diagnose diverticular disease.

🔢 Classification

Severity Classification- Hinchey
I
Peri-colonic abscess
II
Pelvic abscess
III
Purulent peritonitis
IV
Faecal peritonitis

🧰 Management

Uncomplicated diverticular disease may be managed by:

  • Analgesia
  • Oral fluid intake
  • Increase dietary fibre intake
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🌋
What is a phlegmon? It is an inflammatory mass, similar to an abscess as it contains pus, however, it is found in small pockets within the tissue that may become inflamed or infected
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DIVERTICULITIS

😷 Presentation

  • LIF pain (or RIF in Asian patients).
  • Nausea and vomiting due to ileus or colonic obstruction.
  • Constipation is more common than diarrhoea
  • Urinary urgency or dysuria due to bladder irritation by the inflamed bowel
  • PR bleeding
  • Low-grade fever
  • Tachycardia
  • Tender LIF with palpable mass in 20% of patients
  • Guarding and rebound tenderness (if complicated)

🔍 Investigations

  • WCC ⬆️
  • CRP ⬆️
  • AXR - may show pneumoperitoneum if perforated. Other findings may include dilated bowel loops, obstruction or abscesses
  • CT - best to identify abscesses
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Colonoscopy should be avoided in the beginning as it increases risk of perforation.

🧰 Management

  • Increase fibre intake
  • Antibiotics - oral initially (co-amoxiclav) and if not resolving in 72 hours patient should be admitted for IV.
    • IV ceftriaxone + metronidazole is indicated.
  • Drainage - for peri-colonic abscesses.
  • Resection - for recurrent acute diverticulitis.
  • Hinchey IV requires resection and stoma. This is known as Hartmann’s procedure.
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🚨 Complications

  • Colovaginal fistula - can develop at any point, during acute episodes or following the resolution of diverticulitis. Due to the fistula, continuous leakage of faecal matter can pass via the vagina, appearing as if the woman has faecal incontinence.