Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

About

• Disease most commonly seen in the elderly.
• Significant morbidity in those immunosuppressed on steroids.

Aetiology

• Disease is mostly seen in the sigmoid colon.
• Pouches of mucosa and submucosa herniate through the muscular wall of the bowel at points of weakness.
• Tends to affect the sigmoid colon with the presence of diverticula.
• Possibly high intraluminal pressures cause outpouching of mucosa around the areas of blood vessels.
• Alternatively there may be a local neural problem. Low fibre western diets may play a role

Risks

• Old Age, Overweight, lack of exercise
• Smoking, High fat-low fibre diet

Types

• Diverticulosis - presence of diverticulae in the large bowel
• Diverticular disease - diverticulosis associated with its complications
• Diverticulitis - inflammation of diverticulae when the neck of the diverticulae becomes blocked by faeces and infection supervenes

Clinical

• Diverticulae are clinically silent in 90% and very common
• Diverticulitis can cause left sided iliac fossa pain is classical
• Right sided disease may be seen in Asians
• Fever, nausea, vomiting, constipation or diarrhoea
• Frank bleeding PR

Complications

• Diverticulitis, Pericolic abscess
• Fistula formation to bladder, vagina, small intestine
• Perforation and peritonitis
• Local narrowing and stricture formation and Intestinal obstruction

Investigations

• FBC with Diverticulitis - ↑ ESR/CRP/WCC
• U&E, LFTs: may be dehydrated
• AXR and erect CXR may be needed
• Ultrasound scan is useful to show mucosal thickness and exclude an abscess and pericolic fluid
• Barium Enema - may demonstrate the presence of diverticulae.
• Computed tomography (CT) scan of the abdomen and pelvis to establish the diagnosis, determine the extent and severity of disease, and exclude any complications.
• Urgent colonoscopy to establish the diagnosis and treat the source of bleeding if there is diverticular haemorrhage.
• Planned colonoscopy or CT colonography in selected patients to confirm cause

Differentials

• Inflammatory bowel disease
• Ischaemic colitis
• Colorectal cancer

Hinchey Classification

• Stage 0: clinical: mild clinical diverticulitis. CT: diverticula with colonic wall thickening
• stage IA: clinical: confined pericolic inflammation or phlegmon CT: pericolic soft tissue changes
• stage Ib:clinical: pericolic or mesocolic abscess CT: Ia changes and pericolic or mesocolic abscess
• stage II:clinical: pelvic, distant intra-abdominal or retroperitoneal abscess CT: Ia changes and distant abscess, usually deep pelvic
• stage III:clinical: generalised purulent peritonitis CT: localised or generalised ascites, pneumoperitoneum, peritoneal thickening
• stage IV:?clinical: generalised faecal peritonitis CT: same as stage II

Diverticular disease

Management

• Prevention: A high fibre diet is recommended in asymptomatic disease.
• Acute Diverticulitis
  • Mild and uncomplicated acute diverticulitis then consider prescribing oral antibiotics if there is suspected infection. If needed, prescribe at least one week of Co-Amoxiclav (or a combination of Cefalexin with Metronidazole or Trimethoprim with Metronidazole or Ciprofloxacin and Metronidazole if the person is allergic to penicillin). Avoid NSAIDs and opioid analgesia. May be managed as an outpatient. Ensure follow up.
  • Moderate to Severe Acute diverticulitis: Admission, rest, IV fluids and IV Antibiotics. Avoid NSAIDs and opioid analgesia if possible, due to the potential increased risk of diverticular perforation. Recommend clear liquids only, with the gradual reintroduction of solid food if symptoms improve over the following 2-3 days. Consider checking blood for raised white cell count and C-reactive protein (CRP), which may suggest infection.
• Complications
  • Acute Haemorrhage : may be seen with diverticular disease. Usually managed conservatively acutely. It may require urgent blood transfusion. Investigations required include colonoscopy or sigmoidoscopy to see source.
  • Perforation and Peritonitis : Surgery may be for perforation and peritonitis.
  • Fistula formation: Bladder 65%, Vagina 25% and Enteric 10%
• Surgery: open surgery may be needed. Alternative include Laparoscopic surgery . IV antibiotics. An open Hartmann's procedure may be needed.

References

• Diverticular disease NICE 2019