Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

📖 About

• 👵 Most common in the elderly (prevalence rises steeply after 60).
• ⚠️ Higher morbidity in immunosuppressed patients or those on steroids.
• 📈 Lifetime risk of diverticulitis ≈ 4–25% in those with diverticulosis.

🧬 Aetiology & Pathophysiology

• Predominantly affects the sigmoid colon (narrowest lumen, highest pressures).
• Diverticula = herniation of mucosa/submucosa through points of weakness (where vasa recta penetrate the muscle wall).
• High intraluminal pressure → mucosal outpouchings → diverticula formation.
• Western low-fibre diet, altered gut microbiome, and local motility/neurological abnormalities are key contributors.

⚠️ Risk Factors

• Ageing → loss of connective tissue strength.
• Obesity, sedentary lifestyle, smoking 🚬.
• Diets high in fat & low in fibre 🍔.
• Genetic predisposition (family clustering observed).

• Diverticulosis → presence of diverticulae (usually asymptomatic).
• Diverticular Disease → diverticulosis + symptoms/complications.
• Diverticulitis → inflamed diverticula, usually due to faecolith obstruction.

🩺 Clinical Features

• 90% asymptomatic (“silent” diverticula).
• Classic symptom: LLQ/Left iliac fossa pain 🔥.
• Asian populations → more likely to have right-sided disease.
• Associated: fever, nausea, vomiting 🤢, bowel habit changes (constipation/diarrhoea).
• Rectal bleeding (painless, fresh) may occur 💉.

🚨 Complications

• Pericolic abscess.
• Fistulae → bladder (colovesical, pneumaturia), vagina, small intestine.
• Perforation → peritonitis (life-threatening).
• Strictures → bowel obstruction.
• Mass effect can mimic colorectal cancer 🎭.

🔎 Investigations

• Bloods: ↑WCC, ↑CRP, ↑ESR in acute inflammation.
• Imaging:
  • CT Abdomen/Pelvis = gold standard (diagnosis, staging via Hinchey, complications).
  • AXR/CXR → perforation signs (free air, ileus).
  • USS → useful for abscess, wall thickening.
• Endoscopy: avoided acutely (risk of perforation). → Colonoscopy/CT colonography later for assessment, exclude malignancy.

📊 Hinchey Classification (CT Staging)

🛠️ Management

• Prevention: high-fibre diet, weight loss, exercise 🥗.
• Uncomplicated diverticulitis (mild):
  • Oral antibiotics (Co-amoxiclav OR cefalexin metronidazole).
  • Outpatient management, avoid NSAIDs/opioids.
• Moderate-Severe disease:
  • Hospital admission.
  • IV fluids, IV antibiotics, bowel rest.
  • Monitor inflammatory markers.
• Complications:
  • Bleeding → conservative ± colonoscopic therapy.
  • Abscess → percutaneous drainage.
  • Perforation/peritonitis → emergency surgery.
  • Fistula/obstruction → elective surgical resection.
• Surgery:
  • Laparoscopic resection (preferred if feasible).
  • Hartmann’s procedure in severe/generalised peritonitis 💀.

📚 References

• NICE CKS – Diverticular Disease (2019)
• ACPGBI Guidelines for Colorectal Surgery

Cases — Diverticular Disease

• Case 1 — Asymptomatic Diverticulosis: A 60-year-old man undergoes colonoscopy after a positive FIT screening test. Multiple diverticula are seen in the sigmoid colon, but the patient has no abdominal symptoms. Diagnosis: Diverticulosis (asymptomatic). Management: High-fibre diet, hydration advice, reassurance; no treatment needed unless symptomatic.
• Case 2 — Symptomatic Uncomplicated Diverticular Disease: A 55-year-old woman presents with intermittent left iliac fossa pain, bloating, and constipation. She has no fever or systemic features. Colonoscopy 6 months earlier showed sigmoid diverticula. Diagnosis: Symptomatic diverticular disease (uncomplicated). Management: Dietary modification (high-fibre diet), bulk-forming laxatives, analgesia (avoid NSAIDs/opioids). Outpatient follow-up.
• Case 3 — Acute Diverticulitis with Abscess: A 70-year-old man presents with acute left lower quadrant pain, fever, and tachycardia. Exam: localised peritonism. Bloods: raised WCC and CRP. CT abdomen: sigmoid diverticulitis with a 4 cm pericolic abscess. Diagnosis: Complicated acute diverticulitis. Management: Admit, IV fluids, broad-spectrum antibiotics, analgesia. Percutaneous abscess drainage under radiological guidance. Surgery if generalised peritonitis or failure of conservative management.

Teaching Commentary 🥼

Diverticular disease is common in older adults in Western populations, most often in the sigmoid colon. Spectrum: - Diverticulosis = presence of diverticula, often asymptomatic. - Diverticular disease = chronic abdominal symptoms from diverticula. - Acute diverticulitis = inflammation, may lead to abscess, perforation, fistula, or obstruction. Diagnosis is usually via CT in the acute setting. Management: supportive + antibiotics for acute disease, surgery for complications (Hartmann’s procedure if perforated with peritonitis). Long-term advice = high-fibre diet, avoid NSAIDs, ensure colorectal cancer screening as appropriate.