Diverticular disease

Diverticulum = an out-pouching of the wall of the gut

Diverticulosis = the presence of diverticula

Diverticulitis = inflammation of a diverticulum

Pathology:

• Most occur in the sigmoid colon (95% of complications occur at this site)
• Lack of dietary fibre is thought to lead to high intraluminal pressures which force the mucosa to herniate through the muscle layers of the gut
• 1/3 of the western world population has diverticulosis by age 60yrs

Diagnosis:

PR exam

Sigmoidoscopy

Barium enema

Colonoscopy

Differential dx:

• Colorectal cancer
• Pelvic abscess

Complications:

1. Painful diverticular disease:

• Altered bowel habit
• Left-sided, colicky pain that is relieved by defaecation
• Nausea/flatulence
• Rx is: - High fibre diet

- Antispasmodics (e.g. Mebeverine 135mg/8h po)

- Surgical resection (occasionally)

2. Diverticulitis:

• All of the above + signs of inflammation (pyrexia, inc WCC, inc ESR)
• Colon is tender
• Local/general peritonism
• Rx is: - Bed rest

- NBM

- IV fluids

- A/Bs (Cefuroxime 1.5g/8h IV + Metronidazole 500mg/8h IV/PR) until culture results available

3. Perforation:

• Ileus
• Peritonitis ± shock
• Rx is emergency laparotomy (perform Hartman’s procedure – temporary colostomy + partial colectomy)
• Mortality is approx. 40%

Diverticular disease

4. Haemorrhage:

• Sudden and painless
• Diverticular disease is a common cause of big rectal bleeds
• Bleeding usually stops with bed rest
• Transfusion may be necessary
• Other Rx: - Embolization

- Colonic resection

5. Fistulae:

• May form between the colon and the:
• Bladder (leading to pneumaturia/intractable UTIs)
• Vagina
• Small bowel
• Rx is surgical

6. Abscesses:

• Swinging fever
• Leucocytosis
• Localizing signs (e.g. boggy rectal mass)
• If NO localizing signs, remember:
• “Pus somewhere, pus nowhere = pus under the diaphragm”

• Do urgent US to exclude subphrenic abscess (a ‘horrible way to die’)
• Rx is drainage and A/Bs

7. Post-infective strictures:

• May form in the sigmoid colon
• Rx is surgical