Diverticular Disease

 

• Definitions

  • Diverticular disease (aka diverticulosis) is the presence of diverticula (sing. diverticulum), small outpouchings of the colonic mucosa and submucosa though the muscular layer.
  • Diverticulitis is when one of these pouches becomes acutely inflamed (often infectious) and symptomatic.
  • Meckel's diverticulum is a congenital diverticulum which usually presents in infancy, but can present in adults.

• Presentation

  It is usually asymptomatic, or presents non-specifically e.g. pain, bloating, constipation with occasional diarrhoea. A minority of patients suffer painless PR bleeds or diverticulitis.

  Diverticulitis

  Acute presentation:

  • Left iliac fossa pain ± guarding.
  • Diarrhoea, PR mucus or blood. However, PR bleeding more commonly occurs in isolation from diverticulitis.
  • Fever
  • Anorexia, nausea, and vomiting.
  • May be preceded by several months of altered bowel habit, reflecting the underlying diverticulosis.
  • Perforated diverticulitis may present with sudden onset pain and peritonitis.

  Complications:

  • Perforation may lead to fistula (colovesical or colovaginal), abscess (may be palpable), or peritonitis.
  • Recurrence (1/3) after first episode of diverticulitis.
  • Stricture may form during healing after diverticulitis. Can lead to obstruction.

• Risk factors

  • Age: affects majority of people >50 years old.
  • Low fibre diet.

• Investigations for diverticulitis

  • FBC: ↑WCC.
  • CT abdo.
  • Colonoscopy if there is diagnostic doubt or suspected cancer.

• Management

  Uncomplicated diverticular disease

  • No treatment if no symptoms.
  • Otherwise high-fibre diet. No evidence for the traditional advice about avoiding seeds and nuts.

  Diverticulitis

  Medical:

  • Can be managed with oral antibiotics and clear-fluid diet at home if stable. Recent evidence suggests that mild uncomplicated cases can even be managed without antibiotics, as the etiology is thought to be more inflammatory than infectious.
  • Hospital admission and possible IV antibiotics if symptoms persist, transfusion needed, or pain and hydration cannot be maintained.
  • Small abscesses (<3 cm) can often be managed with IV antibiotics alone.

  Surgical and interventional:

  • Abscess >3 cm: CT-guided aspiration, either percutaneous or transrectal (if deep). Surgery if unsuccessful.
  • Indications for surgery: perforation and peritonitis, sepsis, fistula, obstruction. Obstruction may be due to stricture or pseudo-obstruction, the latter sometimes responding to medical therapy.
  • 25% of those hospitalised will need surgery.
  • Surgery usually involves resection, often as part of Hartmann's procedure, which results in a temporary end colostomy and oversewn rectal stump.

  Hinchey classification can also help guide management of complicated disease:

  1. Pericolic abscess: supportive, including IV antibiotics.
  2. Pelvic or retroperitoneal abscess: transrectal drainage.
  3. Purulent peritonitis: laparoscopy and lavage.
  4. Faecal peritonitis: laparoscopy, lavage, and Hartmann's.

  Other presentations

  • Lower GI bleed: endoscopic haemostasis or angiographic embolisation. Surgery if unsuccessful.
  • Bowel obstruction: stenting, balloon dilation, or resection.