What is Diverticular Disease?
- Presence of diverticula
(plural diverticulum)
– pouches protruding outwards from the large intestine wall
– small mucosal herniations protruding through intestinal
layers and smooth muscle
What are the Symptoms of Diverticular Disease?
- Intermittent pain in lower left quadrant (with constipation, diarrhoea, rectal bleeds)
- Abdominal pain worsened by eating, relieved by passing stool or wind
- Flatulence
- Lower left quadrant tenderness on palpation ( R-S= Asian population)
What other condition can symptoms of Diverticular Disease overlap with? Does it have systemic symptoms?
- Symptoms can overlap with other conditions, such as
IBS - No systemic symptoms
What is Diverticulosis?
- Diverticulosis
– condition where uninflamed diverticula
– Usually asymptomatic
Diverticular disease is not Symptomatic? T/F
– symptomatic
What is Diverticulitis?
Condition where one or more inflamed/infected diverticula
Where is Diverticular Common? And what is lacked in patents with the disease?
- Diverticular disease is very common, particularly in industrialised countries
– Westernisation increases incidence
– Lack of fibre
What is the Prevalence of Diverticular Disease?
– similar in males and females
– increases with age
– rare in people aged <40 years
– 1/3 people >65 years, >65% people >85 yrs
What Percentage of patients with Diverticular Disease will remain asymptomatic?
80-85%
What percentage of patients with Diverticulosis develop Diverticulitis?
Approx 5% of patients with Diverticulosis develop Diverticulitis
What percentage of patients with Diverticulitis develop complications requiring surgery?
15-25%
Mortality associated with these
– Abscess formation
– Intestinal rupture
– Fistulas (inflammation/abcess causes passageway)
– Peritonitis (lining abdominal wall and organs in abdomen)
– Massive bleeding
- More common in patients
- Immunocompromised
- Anti-inflammatories
- Severe co-morbidities
What factors are thought to be involved in Diverticulitis? Aetiology
– Genetics:
* Left-sided diverticula predominate in the west (sigmoid colon)
* Right-sided predominant in Asians
– Dietary factors:
* Associated with a low fibre diet and constipation
* Associated with obesity
The Causative agents are unknown in Diverticulitis, However what could lead to development of Diverticulitis?
– Increased intraluminal pressure and weakening of
muscle wall thought to be a primary cause
– Abnormal colonic motility
– Defective muscular structure
– Changes in collagen structure eg in aging
How does Diverticulitis develop? Pathogenesis!
- Colonic muscular hypertrophy results in narrowing of lumen and formation of small chamber with high pressure and subsequent diverticula
What is the process by which faecal material or undigested food lead to Diverticulitis?
- Faecal material or undigested food collect in diverticula and cause obstruction
- Mucus secretion and normal bacterial overgrowth lead to
distension of diverticula - Results in vascular compromise and perforations
- Increase in intraluminal pressure and stuck food particles may also damage diverticula wall, resulting in inflammation and necrosis and perforation
- Recurrent attacks lead to scar tissue formation and lumen narrowing
What is the Management of Diverticulosis?
- Asymptomatic
- No need for routine follow ups
- Maintain healthy balanced diet, high in fibre
- Maintain adequate fluid intake
- If overweight, advise about benefit of weight loss, exercise and also smoking cessation to prevent progression.
- If constipated-offer bulk forming laxatives
What are the management of Diverticular Disease?
- High fibre diet
- Bran supplements/Bulk-forming laxatives
- Lifestyle advice as per diverticulosis
- Anti-spasmodics when colic eg alverine, mebeverine,
peppermint oil etc
What drugs should be avoided in Diverticular Disease in terms on management?
- Avoid NSAIDs
- Anti-motility drugs to slow transit time eg codeine
and loperamide should NOT be used - Risk of diverticular perforation
What are the symptoms of Diverticulitis?
- Constant lower left abdominal pain with:
- Fever
- Sudden bowel change
- Blood/mucus in stools
- Lower left quadrant tenderness
- Palpable abdominal mass/distension
- Malaise
- N&V
- Increased WBC, if bleeding occurs, increased platelets,
anaemia, increased CRP
What is the Management of Diverticulitis?
- Refer for hospital assessment if:
- Patient > 65 years
*Co-morbidities/ Immunosuppressed - Can’t take oral Abx at home
- Dehydrated/at risk, can’t rehydrate sufficiently from home
- Uncontrollable abdominal pain plus signs of complicated acute diverticulitis:
What are the signs of COMPLICATED Acute Diverticulitis?
- Intra-abdominal abscess (mass on examination)
- Diverticular haemorrhage
- Peritonitis (rigidity/guarding upon examination)
- Stricture (reduce GI motility, constipation, cramping)
- Fistula formation (faecaluria, pneumaturia, passing faeces
through vagina) - Intestinal obstruction (cramping, absolute constipation, distension)
- Sepsis ( Increased resp, Increased HR, Decreased systolic BP, no urine output, skin discolouration, cognitive impairment
What drugs should be used in Diverticulitis Management in Patients with Acute + Systemically unwell (but don’t need admission)?
- Co-amoxiclav 500/125 TDS x 5 days (Cefalexin if penicillin
allergy) + Metronidazole 400mg TDS x 5 days , OR - Trimethoprim 200mg BD x 5 days + Metronidazole 400mg TDS x 5 days
What drugs should be used in Diverticulitis Management in Patients with Acute + Systemically Well?
- Consider no Abx strategy (antimicrobial stewardship)
- Analgesia e.g. Paracetamol (avoid NSAIDs/opioids)
- Re-present if symptoms worsen
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Rheumatoid Arthritis41
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Biologics & targeted DMARD therapeutics9
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NSAIDS, MTX, LEFLUNOMIDE, CICLOSPORIN THERAPEUTICS58
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IRRITABLE BOWEL SYNDROME (IBS)30
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STOMAS15
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EXOCRINE PANCREATIC INSUFFICIENCY (Mo'C) Lower GI11
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