Acute Diverticulitis

Question 1

Define diverticular disease

Answer 1

Herniation of colonic mucosa through muscular wall of the colon

Question 2

Symptoms of acute diverticulitis

Answer 2

Altered bowel habit
Bleeding
Abdominal Pain

Question 3

Complications

Answer 3

Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phelgmon

Question 4

Diagnosis of diverticulitis

Answer 4

• colonoscopy/CT cologram/barium enema in clinic
• if acutely unwell = abdominal XR to identify perforation
• abdominal CT with oral and IV contrast to detect inflammation and complications such as abscesses

Question 5

Severity of perforations due to diverticulitis

Answer 5

Hinchey
1 = para colonic abscess
2 = pelvic abscess
3 = purulent peritonitis
4 = faecal peritonitis

Question 6

Treatment

Answer 6

• increase fibre
• AB if mild attacks
• peri colonic abscesses drain
• recurrent acute episodes = segmental resection
• Hinchey stage 4 perforation = resection and stoma
• less severe peritonitis = laparoscopy washout and drain insertion

Question 7

Hinchey Stage 4 management

Answer 7

• high risk of post op complications
• require HDU
• Resection and stoma
• less severe peritonitis = laparoscopy washout and drain insertion

Question 8

Define diverticulitis

Answer 8

Infection of out-pouching intestinal mucosa

- as increased intra-abdominal pressure

Question 9

Where does diverticulitis occur?

Answer 9

• weaker areas of wall
• where arteries penetrate
• sigmoid colon mostly

Question 10

RF of diverticulitis

Answer 10

• 50-70 yrs
• age
• low fibre diet
• obesity
• sedentary
• smoking
• NSAIDs

Question 11

Diverticulitis symptoms - chronic

Answer 11

• intermittent abdominal pain in LLQ
• bloating
• bowel habit changes = diarrhoea or constipation

Question 12

Diverticulitis Acute onset symptoms

Answer 12

• severe abdominal pain in LLQ
• N&V
• bowel habit changes
• urinary frequency/urgency/dysuria
• PR bleeding
• pneumaturia or faecaluria

Question 13

How may acute diverticulitis affect Asian patients differently?

Answer 13

RLQ

Question 14

Why do you get N&V?

Answer 14

Colonic obstruction

Question 15

What do pneumaturia or faecaluria suggest?

Answer 15

Colovesical fistula

If in vaginal passage = colovaginal fistula

Question 16

Signs

Answer 16

Low grade pyrexia
Tachycardia
Tender LIF
Sometimes mass in LIF if inflammation/abscess
Reduced bowel sounds?
Guarding, rigidity and rebound tenderness = perforation
Lack of improvement with Tx = abscess

Question 17

Ix

Answer 17

High WCC
High CRP
CXR = pneumoperitoneum if perforation
AXR = dilated bowel loops, obstruction or abscess
CT = best for abscess
Colonoscopy = avoid as perforation risk

Question 18

Tx

Answer 18

Mild = Oral AB, liquid diet, analgesia
If symptoms don’t settle in 72 hours = hospital IV AB
Surgery

Question 19

Indications for surgery

Answer 19

• major rectal bleeding = endoscopic haemastasis
• colonic resection if recurrent diverticulitis
• if generalised purulent peritonitis
• generalised faecal peritonitis

Question 20

What is seen on AXR?

Answer 20

dilated bowel loops, obstruction or abscess

Question 21

What is seen on CXR?

Answer 21

Pneumoperitoneum

Question 22

Why is there changes in urinary symptoms?

Answer 22

Irritation of the bladder by the inflamed bowel