Diverticular disease of the colon

Diverticular disease of the colon

Aetiology & Epidemiology

·        ¯Dietary fibre ® ¯stool weight and ¯colonic transit ® ­colonic pressure

·        50% in > 70 years

Symptoms & Signs:

·        Most asymptomatic

·        Uncomplicated disease (Diverticulosis): non-specific tender sigmoid colon, cramping lower abdominal pain (esp. LIF), altered bowel habit (hard or ribbon like stools, e.g. due to stricture)

·         Complicated disease (Diverticulitis): constant pain worse with movement, fever, shock, peritonitis, haemorrhage, guarding, palpable mass, ileus, distension, obstruction (= “Left sided appendicitis”)

·        PR bleeding not usually concurrent with guarding

Pathology

·        Diverticulosis: multiple out-pouchings or herniations (= diverticula) of the mucosa through the muscle wall of the bowel at the point where arteries penetrate the bowel wall 

·        Diverticulitis: inflammation of the diverticulum caused by obstruction of the neck, faecal impaction, constricted blood supply, infection from luminal flora

·        Complications:

o   Abscesses ® obstruction, bleeding due to erosion of blood vessels

o   Stricture from scarring

Investigations

·        Bloods usually normal in uncomplicated disease: do FBC and LFT

·        Complicated disease: inflammatory/infection markers (eg blood cultures if temp > 38 C)

·        CT, ultrasound, colonoscopy 

·        Contrast enema one month later (never acutely – risk of perforation) to confirm diverticulum and exclude cancer

Differential

·        Cancer

·        Inflammatory bowel disease

·        Drug induced colonic symptoms

·        Abscess/perforation: pyelonephritis, perforated peptic ulcer, ischaemic colitis

·        Haemorrhage: polyp, angiodysplasia, GI bleeding

·        Stricture: radiation damage, ischaemic colitis, endometriosis

·        Malabsorption: lactose intolerance, coeliac disease

·        Infection: campylobacter, other infection

Treatment:

·        Acute management:

o  Fluids (nil by mouth to rest gut) 

o  For diverticulitis: antibiotics (eg cefuroxime and Metronidazole. If really nasty then Gentamycin, Amoxycillin and Metronidazole)

o  Epidural would be good for pain but is contraindicated if risk of sepsis

o  Usually settles with conservative management.  If not, then resect affected colon:

§  Hartman‟s procedure: Remove affected segment.  Bring proximal bowel out to a colonostomy.

§  Temporarily close off distal segment

§  Reverse colonostomy 3 months later

·        Chronic management:

o  ­Fibre, ­fluids, ­exercise

o  For constipation: bulking agents, lactulose

o  For pain relief: anticholinergics (cicyclomine), antispasmodics