Diverticular disease

From Ganfyd

A diverticulum is a chronic outpouching of a hollow viscus into the surrounding tissues. When not specified, diverticular disease is refers to diverticula occuring in the colon. Some prefer to use the term diverticulosis to describe the presence of diverticular, and the term diverticular disease only when it causes symptoms.

Diverticula can be classified as 'false' (c.f. 'false' and 'true' aneurysms) because they involve pockets of mucosa protruding through the taenia coli. c.f. Meckel's diverticulum which is a 'true' diverticulum involving all layers of the bowel wall.

Characteristics

• Shares symptoms with irritable bowel syndrome & chronic constipation
  • Intermittent attacks of abdominal pain
  • Erratic bowel habit
  • Abdominal bloating and passage of excessive flatus
• Chronic lack of fibre
• At least third of population over 60
• Females > Males
• Pockets of mucosa herniate through weakness in bowel wall - where mucosal blood vessels penetrate

The distribution in Western populations is mainly left-sided, particularly the sigmoid colon, but in Asians, there is a higher proportion of right-sided diverticula.^[1]

Complications

• Diverticulitis, with further complications from the resulting inflammation, e.g.
  • Spreading pericolic inflammation
  • Pericolic abscess
  • Intraperitoneal perforation
  • Fistula formation into other abdominal or pelvic viscera
  • Bowel to bowel adhesions
  • Fibrous strictures of bowel
• acute rectal haemorrhage

Presentations

• Chronic grumbling diverticular pain
  • chronic pain
  • erratic bowel habit
  • chronic constipation
  •  ? mild left iliac fossa tenderness
• Acute diverticulitis
  • continuous left iliac fossa pain (ranging from mild tenderness → obvious local peritonitis)
  • pyrexia
  • tachycardia
  • Managed with Abx against usual faecal organisms
  • e.g. Metronidazole +/- amoxycillin/cephalosporin
  • Severe cases - gentamicin, metronidazole and benzylpenicillin and bowel rested (NBM and IV fluids)
• Pericolic abscess
  • persistent pain and tenderness
  • swinging pyrexia
  • incomplete obstruction
  • sometimes sepsis or PUO
  • (may be presentation of perforated carcinoma)
  • Antibiotic treatment or operation
• Diverticular perforation
• Acute rectal haemorrhage
  • main differential diagnosis is ischaemic colitis
  • consider carcinoma, haemorrhoids
• Fistula formation
• Intestinal obstruction

References