Sponsors

You're browsing as an anonymous user. Join the community today to view notes at your university, edit pages, and share knowledge!

Diverticular Disease

From Mediwikis


Whilst diverticula may be present in any hollow structure, this page refers specifically to those acquired in the intestines. For congenital diverticula in the gut, see Meckel's diverticulum.[1]

Definitions

Confused by all of medicine's ever-perplexing terminology? Aren't we all?

Here are the terms you will need to understand for this article:[2][3]

diverticulum herniation of the gut mucosa
diverticulosis presence of diverticula
diverticulitis inflammation of diverticula
diverticular disease diverticula are symptomatic

Epidemiology

  • diverticulosis is present in 30% >60 years and 70% >80 years[2][3]
  • rarely found in those <40 years[3]
  • 1-4% of patients with diverticulosis develop diverticular disease[4]
  • recurrence rates may be as high as 36%[5]

Aetiology

  • lack of dietary fibre → high intraluminal pressures → mucosa forced to herniate through muscle layers of the gut → diverticula formed[2]
  • herniation occurs at weak points, particularly adjacent to the entry sites of perforating arteries
  • 95% occur in the sigmoid colon[2]
  • other risk factors:[6][7][8]
    • family history
    • obesity
    • smoking
    • NSAIDs
    • aspirin
    • oral corticosteroids

Clinical Features[2]

Investigations & Diagnosis[2][3]

  • blood tests: WCC ↑ CRP ↑ ESR ↑ in diverticulitis
  • CT abdomen
    • best in acute setting
  • barium enema
  • colonoscopy
    • diverticulosis is a common incidental finding
    • risk of perforation in acute setting - best postponed until 6–8 weeks after acute diverticulitis
  • abdominal x-ray
    • may identify obstruction, perforation or vesical fistulae

Management

Diverticular Disease[2]

  • high fibre diet (grains, fruit, vegetables)
  • laxatives e.g. lactulose
  • anti-spasmodics e.g. mebeverine 135 mg TDS

Diverticulitis[2][3]

  • mild:
    • bowel rest (fluids only)
    • oral antibiotics: co-amoxiclav
    • analgesics: paracetamol
  • moderate-severe:
    • NBM and IV fluids
    • IV antibiotics: vancomycin
    • analgesics: pethidine

Complications[2][3][9]

  • haemorrhage
    • sudden and painless
    • usually self-limiting
  • sepsis
    • antibiotics e.g. co-amoxiclav
  • obstruction
    • NBM, nasogastric tube + IV fluids
    • sigmoidoscopy and flatus tube
    • surgery e.g. colonic resection
  • perforation
  • fistulae
    • may be eneterocolic, colovaginal or colovesical
    • surgery e.g. colonic resection

References

  1. Snyder CL. Meckel Diverticulum. In: Coran AG et al. Paediatric Surgery. 7th ed. Missouri: Mosby, 2012, 1085-92.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Longmore M et al. Oxford Handbook of Clinical Medicine. 9th ed. Oxford: Oxford University Press, 2014.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Gaglia A, Probert CS. Diverticular Disease. Diverticular Disease 2015;43(6):320-3.
  4. Shahedi KFG, Bolus R et al. Progression from incidental diverticulosis to acute diverticulitis. Gastroenterology 2012;142(suppl. 1):S144.
  5. Gervaz P et al. A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2. Colorectal Dis 20012;14:463-8.
  6. Hjern F, Wolk A, Hakansson N. Smoking and the risk of diverticular disease in women. British Journal of Surgery 2011;98:991-1002.
  7. Hjern F, Wolk A, Hakansson N. Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study. Am J Gastroenterol 2012;107:296-302.
  8. Strate LL et al. Use of aspirin or non steroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011;140:1427-33.
  9. Coyne PE, Kalbassi MR. Diverticular disease. Intestinal Surgery II 2014;32(8):431-4.