Colonic Diverticula

Question 1

What are the types of colonic diverticula?

Answer 1

• congenital/true -> all layers (Meckle’s diverticulum)

- aquired/false -> only mucosa & submucosa (sigmoid colon)

Question 2

What are the causes of diverticula in the colon?

Answer 2

• diet low in fiber & rich in fat & red meat
• obesity
• low physical activity
• chronic constipation

Question 3

What is the pathophysiology of colonic diverticula?

Answer 3

• increased intraluminal pressure
• altered collagen structure with aging (>60)
• weakness of intestinal wall (occurs in the gaps where the blood vessels penetrate)
• in sigmoid colon most common: highest pressure & narrowest lumen

Question 4

What is the clinical presentation of colonic diverticula?

Answer 4

• asymptomatic
• distention
• flatulence
• heaviness in left iliac fossa

Question 5

When should colonoscopy be used?

Answer 5

only if symptomatic

- diffuse diverticulosis

Question 6

How is colonic diverticula managed?

Answer 6

• no treatment unless symptoms are severe -> sigmoidectomy
• prevention of progression
• > high fiber diet
• > physical activity
• > bulk-forming laxative
• > antispasmodics

Question 7

What are the complications of colonic diverticula?

Answer 7

• hemorrhage
• diverticulitis
• abscess
• peritonitis
• fistula -> colovesical
• intestinal obstruction

Question 8

What is the presentation of diverticulitis?

Answer 8

• persistent LIF pain
• fever
• diarrhea or constipation
• hematochezia
• tender palpable LIF mass
• shock & peritoneal signs: perforation peritonitis

Question 9

What is the classification of diverticulitis?

Answer 9

GRADE I -> mesenteric or pericolic abscess
GRADE II -> pelvic abscess
GRADE III -> purulent peritonitis
GRADE IV -> faecal peritonitis

Question 10

What workups should be done for diverticulitis?

Answer 10

• CBC
• CRP
• if shock: ABG, LFT, coagulation
• abdominal x-ray -> if perforation pneumoperitoneum
• CT abdomen & pelvis with IV contrast

Question 11

How is mild diverticulitis (Hinchey 0-1) managed?

Answer 11

• > antibiotics (ciprofloxacin + metronidazole)
• > analgesics
• > NPO or clear fluid diet for 48 hours then low fiber diet till recovery
• > colonoscopy 6-8 weeks after recovery

Question 12

How is Hinchey 2 (abscess ) managed?

Answer 12

• percutaneous drainage if abscess is >4-5cm

Question 13

How is Hinchey 3-4 (peritonitis) managed?

Answer 13

• urgent surgery
• Hartmann’s procedure -> sigmoidectomy + end colostomy
  mortality rate 50%

Question 14

How is recurrent diverticulitis treated (0-2)?

Answer 14

• elective sigmoidectomy with colorectal anastomosis (laparoscopic)

Question 15

What is the presentation of a colovesical fistula?

Answer 15

• fecaluria
• pneumaturia
• recurrent UTI

Question 16

What is the presentation of colovaginal fistula?

Answer 16

• common after hysterectomy

- vaginal gas/fecal emission

Question 17

What will a retroperitoneal fistula lead to?

Answer 17

psoas abscess