Introduction

Diverticulosis is the mucosal outpouching of the gut wall. It is common and more prevalent with advancing age, increasing from 30% at age 60 to 65% at 85. Risk is also increased in those with sedentary lifestyles and diets lacking fibre. Medical intervention is only indicated, however, when complications caused by diverticulosis arise. These complications make the diverticulae symptomatic, and upgrade diverticulosis into diverticular disease. Medical management is entirely dependent on the nature of the complications developed. The two most common and important complications of diverticulosis are diverticulitis and diverticular bleeding, and these do not usually co-exist. In the West, the sigmoid colon is a common site of diverticulosis. Of these, 70% remain asymptomatic, 15-25% develop diverticulitis, and 5-15% develop some form of diverticular bleeding. 

Basic definitions used when discussing Diverticular Disease

Pathology

Diverticulosis

A lack of dietary fibre is thought to lead to high intraluminal pressures in the gut. This forces the mucosa to herniate through the muscle layers of the gut at weak points, such as the sites of entry of perforating arteries.

 

Diverticulitis

The diverticular wall is eroded as a result of the high intraluminal pressure or inspissated (thickened, as by evaporation or fluid absorption) food particles. This erosion results in inflammation and focal necrosis ensues, causing microscopic or macroscopic perforation. Complicated diverticulitis refers to the presence of at least one of the following: abscesses, fistulae, obstructions, perforations. Simple diverticulitis refers to inflammation in the absence of all these.

 

Diverticular bleeding

Ruptured blood vessels bleed into the diverticulum and the lumen of the gut, eventually exiting the GI system painlessly as blood in the back passage. Bleeding can be occult (within stool) or frank (with the passage of maroon or bright red blood). 

Clinical Manifestations of Diverticulitis

Diverticulitis

Clinical Manifestations of Diverticular Bleeding

Diverticular Bleeding

Sequence of Investigations

This is a logical sequence of investigations that one might want to follow whilst attempting to diag

If first-line investigations do not reveal anything significant, or if further confirmation is needed, other investigations may also be done.

These include Sigmoidoscopy, Ultrasonography and Bloods (Look out for increased white cell count and increased CRP/ESR).

Management

Treat the initial acute presentation of diverticular disease, especially if acute, conservatively. Patients should be encouraged to switch to a diet that is high in fibre, as well as exercise more, since this may help prevent the development of further symptomatic diverticulae. On top of this, antispasmodics (e.g. mebeverine 135mg/8h PO) should also be offered.

Further treatments depend on complications of the diverticula (15-30% will need surgery). Indications for surgical resection are:

  • Purulent or faecal peritonitis
  • Uncontrolled sepsis
  • Fistula
  • Obstruction
  • Inability to exclude carcinoma

 

Complication-specific management:

 

Perforation

  • At laparotomy , temporary colostomy and partial colectomy (Hartman’s procedure) may be performed
  • Colonic lavage may be done the appendix stump, then immediate primary anastomosis (avoiding repeat surgery to close the colostomy)

 

Haemorrhage

  • If severe, immediate fluid and blood product resuscitation is required
  • Bed rest
  • Blood transfusion
  • Embolization or colonic resection may be necessary after locating bleeding points by angiography or colonoscopy
  • Surgery may not need to be done if diathermy with or without local adrenaline injections is done

 

Fistulae

  • Single-stage resection with fistula closure done for colovesical fistulas
  • Surgical resection of colon with vaginal repair done for colovaginal fistulas

 

Abscesses

  • Small abscesses treated with antibiotics and bowel rest
  • Antibiotic with ultrasound  or CT-guided percutaneous drainage might be needed if there is a subphrenic abscess
  • Single stage resection and anastomosis can be done where possible, but not in preference to drainage

 

Obstruction

  • Watchful waiting
  • If malignant disease cannot be excluded in strictures, they have to be resected
  • Endoscopic balloon dilatation possible if neoplasm excluded
  • Stenting for temporary decompression, preparatory for single-stage resection without diversion 

Prognosis

70% of patients with anatomical diverticulosis remain asymptomatic, and most complications are most severe only on initial presentation. Mortality and morbidity are linked to the severity of the disease, and occur in 10-20% of patients with diverticulosis during their lifetime. 

Other useful resources

 

http://www.patient.co.uk/doctor/Diverticular-Disease.htm

http://hcd2.bupa.co.uk/fact_sheets/html/diverticular_disease.html

http://www.mayoclinic.com/health/diverticulitis/DS00070

These are several websites where you can learn more about diverticular disease, although they are especially useful in providing contrasting views (between US and UK healthcare systems) on the way that the disease is managed. (First two links are to UK websites, third link is to a US website)

 

http://www.youtube.com/watch?v=CD1GgwLKBmw

This link is to a video showing laparoscopic sigmoid colectomy for diverticular disease. It was done by Prof. Nabil Shedid. With regards to medical student curricula in the UK, it is not necessary to learn and understand what's going on. It is, however, interesting to watch!

 

http://www.youtube.com/watch?v=3xkq4VkWUO8

This is a link to a short lecture on diverticular disease by PLAN (Prescriptive Learning for All Nurses) from ATI. It is fairly informative and simple to understand.

References

 

Longmore M., Wilkinson I., et al. Oxford handbook of clinical medicine 8th Edition (2010). Oxford University Press

Tonia Young-Fadok, MD and John H Pemberton, MD. "Clinical Manifestations and Diagnosis of Colonic Diverticular Disease." UpToDate Inc. Ed. J. Thomas LaMont, MD and Anne C. Travis, MD, MSc, FACG. 28 Sept. 2010. Web. 5 Dec. 2010. .

Dr Colin Tidy. "Diverticular Disease." Patient UK. Ed. independent Mentor GP reviewing team of EMIS. 19 Apr. 2008. Web. 5 Dec. 2010. .

 

 

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