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Chapter: Medicine and surgery: Gastrointestinal system

Diverticular disease - Disorders of the large bowel and inflammatory bowel disease

A diverticulum is a mucosal outpouching, diverticular disease is a general term that encompasses diverticulosis (the presence of diverticula) and diverticulitis (inflammation of a diverticulum). - Definition, Incidence, Aetiology, Pathophysiology, Clinical features, Complications, Investigations, Management, Prognosis.

Disorders of the large bowel and inflammatory bowel disease


Diverticular disease

 

Definition

 

A diverticulum is a mucosal outpouching, diverticular disease is a general term that encompasses diverticulosis (the presence of diverticula) and diverticulitis (inflammation of a diverticulum).

 

Incidence

 

Rare before the age of 35, but by 65 years one third of the population is affected.

 

Geography

 

Primarily a Western condition (due to diet). Immigrants to the West are also at risk.

 

Aetiology

 

Diverticulae are associated with high intraluminal pressure, muscle hypertrophy can be seen before diverticulae develop. There is a relationship with a low fibre diet and chronic constipation.

 

Pathophysiology

 

They occur most commonly in the sigmoid colon and may become obstructed with a faecolith. Repeated inflammation and scarring may result in an ulcer difficult to distinguish from carcinoma. Diverticulitis is caused by obstruction of the neck of the diverticulum resulting in mucosal inflammation.

 

Clinical features

 

Diverticulosis is frequently asymptomatic. Patients may however report intermittent lower abdominal and left iliac fossa pain, altered bowel habit or occasional minor rectal bleeding.

 

Diverticulitis presents as pyrexia, nausea, vomiting, with pain and tenderness, a mass may be palpable.

 

Macroscopy/micropscopy

 

On the surface of an opened section the slit like openings of diverticula can be seen.

 

Complications

 

·        Perforation presents as an acute abdomen with peritonitis.

 

·        Bleeding which may be significant.

 

·        Obstruction due to oedema, fibrosis or adherence of small bowel loops.

 

·        Stricture formation in long-standing disease difficult to differentiate from malignant strictures.

 

·        Fistulae may occur to skin or viscera. A colovesical fistula presents with painful passage of pneumaturia.

 

Investigations

 

Barium enema can be used to demonstrate the presence of diverticulae. They may be seen on colonoscopy (contraindicated in acute diverticulitis).

 

Management

 

Most patients improve on a high-fibre diet and bulk-forming laxatives such as Fybogel.

 

·        Acute diverticulitis is treated with bowel rest, intra-venous fluids and broad-spectrum antibiotics.

 

·        Surgery may be indicated for refractory symptomatic diverticulosis. A sigmoid colectomy and end-to-end anastomosis is performed.

 

·        Perforation is treated with resuscitation and surgical resection. If there is peritonitis a Hartman’s procedure (distal segment is oversewn and returned to the abdomen, proximal segment brought to surface as a colostomy) or exteriorisation of both ends of the bowel is performed, with secondary anastomosis 6–8 weeks later.

 

·        Strictures or obstructions are treated by surgical resection followed by primary or secondary anastomosis.

 

·        Severe bleeding may require embolisation or surgery.

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Medicine and surgery: Gastrointestinal system : Diverticular disease - Disorders of the large bowel and inflammatory bowel disease |


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