Diverticulosis and Diverticular Disease

Diverticulosis and Diverticular Disease Definition Herniations of the colonic mucosa Occurs due to high intraluminal pressure -> at points where it is weakened by penetration of a colonic artery Epidemiology Most commonly on the left side Most commonly sigmoid Common cause of large volume lower GI bleeding Stops spontaneously in 75% of patients Risk Factors Older age 80% of people over85 Low fibre diet Western diet Smoking Obesity Medications NSAIDs and opioids Complicated vs Uncomplicated Diverticular Disease Uncomplicated Complicated Severe abdominal pian Fever Nausea Vomit Signs of infection Anorexia Rectal bleeding Usually asymptomatic Bloating Mild abdominal pain/discomfort Changes in bowel habits LLQ Diarrhoea or constipation Tender abdomen +/- guarding Tachycardia Fever Positive blood culture result Features of peritonitis Abscess of any size Features of sepsis or septic shock Investigations Bloods FBC -> leucocytosis and anaemia Urea and electrolytes -> baseline -> important before CT scans Inflammatory markers -> elevated CRP Group and hold Imaging CT abdomen and pelvis with contrast Contraindicated in AKI -> then may do non-contrast First line imaging modality Findings: Fat stranding -> inflammation Outpouching Fecalith Enlarged diverticular (in diverticulitis) Abscess Fistulas Bowel wall thickening -> segmental thickening more than 4mm -> characteristic finding May see features of obstruction Management Fibre diet Diverticulosis Colonoscopy not required unless: Imaging abnormalities suggestive of malignancy, abscess or shouldering appearance, inflammatory mass, obstruction or mesenteric or retroperitoneal lymphadenopathy Atypical symptoms Bleeding, narrowed stools Delayed recovery Symptoms do not resolve after a few days Uncomplicated diverticulitis Outpatient without antibiotics if no evidence of complications, comorbidities or immunosuppression Antibiotic therapy indicated when: Immune compromise Right sided diverticulitis Failure to improve after 72 hours of conservative treatment amoxicillin clavulanate 875+125 mg orally, 12-hourly -> adjust dose if have kidney impairment if penicillin allergy: cefuroxime + metronidazole Acute episode of complicated diverticulitis Require colonoscopy 6 to 8 weeks after an episode of acute diverticulitis Empiric: IV Gentamicin + metronidazole + amoxicillin Management of diverticular bleeding If large volume Admission -> risk of hemodynamic instability Stops spontaneously in 75% of patients If bleeding does not stop: Localise via a colonoscopy, red blood cell scanning or CT Aim for haemostasias -> urgent colonoscopy and direct treatment with endoscopic techniques or selective angiography with embolization of bleeding vessel Urgent surgery for patients who continue to bleed and: Hemodynamically unstable despite resuscitation Have had a large volume transfusion Failed endoscopic or radiological attempts at haemostasis If colonoscopy is not performed upon admission due to bleeding cessation with conservative management Arrange for one soon after discharging to rule out other DDx such as cancer Therapy duration Completed diverticulitis + undergone surgery -> 4 days (IV + oral) after adequate surgical control Patients not undergone surgery: Uncomplicate: 5days Complicated: 7 to 10 days (IV + oral) Surgical management Indications: Failure of medical therapy Complications occur Patients with fistula or persistent abscess should be assessed Purulent peritonitis -> laparoscopic lavage or resection Feculent peritonitis -> colonic resection Complications Abscess Most common complication Perforation -> peritonitis Sepsis Fistula Obstruction Bleeding