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

• Diverticular disease is most commonly seen in the elderly population.
• There is significant morbidity in individuals who are immunosuppressed or on steroids.

Aetiology

• The disease predominantly affects the sigmoid colon.
• Diverticula are formed when pouches of mucosa and submucosa herniate through the muscular wall of the bowel at points of weakness.
• High intraluminal pressures may cause outpouching of mucosa around areas of blood vessels.
• Local neural abnormalities and low-fiber Western diets may also contribute to the development of diverticula.

Risks

• Advanced age, overweight, and lack of exercise.
• Smoking and a high-fat, low-fiber diet.

Types

• Diverticulosis: Presence of diverticulae in the large bowel.
• Diverticular Disease: Diverticulosis accompanied by its complications.
• Diverticulitis: Inflammation of diverticulae caused by blockage of the diverticula neck by feces and subsequent infection.

Clinical Presentation

• Diverticulae are clinically silent in approximately 90% of cases and are very common.
• Diverticulitis typically presents with left-sided iliac fossa pain, which is considered classical.
• Right-sided disease may be more prevalent in Asian populations.
• Additional symptoms include fever, nausea, vomiting, constipation or diarrhea.
• Frank rectal bleeding (hematochezia) may occur.

Complications

• Diverticulitis leading to pericolic abscess.
• Fistula formation to adjacent organs such as the bladder, vagina, or small intestine.
• Perforation of the diverticula causing peritonitis.
• Local narrowing and stricture formation resulting in intestinal obstruction.

Investigations

• Laboratory Tests:
  • Full Blood Count (FBC) with elevated ESR, CRP, and WCC in diverticulitis.
  • Urea & Electrolytes (U&E) and Liver Function Tests (LFTs) to assess dehydration.
• Imaging:
  • Abdominal X-Ray (AXR) and erect Chest X-Ray (CXR) if perforation is suspected.
  • Focused Abdominal Sonogram for Trauma (FAST).
  • Ultrasound scan to evaluate mucosal thickness and exclude abscess or pericolic fluid.
  • Computed Tomography (CT) scan of the abdomen and pelvis to confirm diagnosis, assess severity, and identify complications.
  • Barium Enema to demonstrate diverticulae.
  • Urgent colonoscopy for diverticular haemorrhage management.
  • Planned colonoscopy or CT colonography in selected patients for further evaluation.
• Other Procedures:
  • Peritoneal lavage if indicated.
  • Biopsies as needed based on differential diagnoses.

Differential Diagnoses

• Inflammatory Bowel Disease (e.g., Crohn's Disease, Ulcerative Colitis).
• Ischemic Colitis.
• Colorectal Cancer.

Hinchey Classification

Management

• Prevention: A high-fiber diet is recommended for individuals with asymptomatic diverticulosis to prevent complications.
• Acute Diverticulitis:
  • Mild and Uncomplicated: Prescribe oral antibiotics if infection is suspected. Options include:
    • Co-Amoxiclav for at least one week.
    • Combination of Cefalexin with Metronidazole.
    • Combination of Trimethoprim with Metronidazole.
    • Ciprofloxacin and Metronidazole for patients allergic to penicillin.
    Avoid NSAIDs and opioid analgesia. May be managed on an outpatient basis with appropriate follow-up.
  • Moderate to Severe: Hospital admission is required with:
    • Rest and bowel rest (clear liquids only).
    • Intravenous (IV) fluids and IV antibiotics.
    • Avoid NSAIDs and opioid analgesia due to increased risk of perforation.
    • Monitor blood tests for raised white cell count and C-reactive protein (CRP).
• Complications Management:
  • Acute Hemorrhage: Usually managed conservatively initially. May require urgent blood transfusion and colonoscopy or sigmoidoscopy to identify and control the bleeding source.
  • Perforation and Peritonitis: Requires surgical intervention to repair perforation and manage peritonitis.
  • Fistula Formation: Requires surgical repair; common sites include bladder (65%), vagina (25%), and small intestine (10%).
• Surgical Treatment:
  • Open surgery is often necessary in complicated cases.
  • Laparoscopic surgery is an alternative approach.
  • Administration of IV antibiotics post-surgery.
  • Hartmann's procedure (resection of diseased segment with colostomy) may be required in severe cases.

References

• Diverticular Disease NICE 2019