Background
Definition. A weakness in the bowel wall allowing a herniation of the mucosa and submucosa usually at the site where a nutrient vessel penetrates thorough the muscularis.
Classical Triad of
- Fever
- Leukocytosis
- Left lower quadrant pain
- The cause is unknown
- Incidence is increasing
- Increasing incidence with age
- Inflammatory episode (diverticulitis) < 5% before 40 yo, 60% by 85yrs
- Present in 1/3 of those at age 45 and 2/3 by age 85
- More prevalent in Westernised Societies
- M:F ratio is equal but males are more likely to suffer diverticulitis
- Sigmoid colon most commonly affected although any part of the gut can be involved.
- Risk factors:
- Age
- Abnormal Gut Motility (including constipation)
- Family History
- Role of NSAIDs is questionable
Common Clinical Entities:
Diverticulitis
- Pyrexia
- Abdominal Tenderness
- Leukocytosis
Diverticular haemorrhage
- Classically painless (bright red/wine coloured stool)
- May be life threatening esp. in elderly
Diverticular Perforation
- Hippocratic facies
- Rigid abdomen
- Very unwell
History
Symptoms:
- Fever
- Abdominal Pain
- Mild (localized) - Diverticulitis
- Severe (generalized) - Perforation ± feculent peritonitis.
- Back Pain
- Perforation
- Altered bowel habit
- Nausea/Vomiting
- Dysuria/Frequency
- Ask about NSAIDS and Steroids.
Examination
Signs:
- Pyrexia
- Loss of abdominal movement on respiration
- Abdominal Tenderness
- Generalised Tenderness
- Localised Tenderness
- Localised Guarding
- Generalised Guarding
- Abdominal distension
- Renal angle tenderness
- Percussion/Rebound tenderness
- Reduced/Absent bowel sounds
- Remember a PR exam in all (& pelvic exam)
Investigations
- Vital signs - hypovolaemic vs. inflammatory response?
- Pyrexic, Tachycardic, Tachypnoeic, Hypotensive (reduced pulse pressure)
- FBC - elevated WCC?
- U&E - electrolyte abnormalities/co-existing renal disease
- Coag (APTT/PTT) - bleeding diathesis, anti-coagulant therapy
- Erect CXR - Free air present in 80% of perforations
- PFA - Dilated loops of bowel (obstruction). Check - air in Rectum?
- MSU - Pyuria - UTI/Haematuria - renal colic
- FOB - positive? Frank blood vs. occult blood
Differential diagnoses
- Inflammatory Bowel Disease
- Crohn's Disease
- Ulcerative Colitis
- Non-specific colitis
- Ischaemic Colitis
- Neoplasia (conditions may co-exist in up to 12%)
- Adenocarcinoma
- Leiomyosarcoma
- Infective Colitis C. Diff C. Diff 027
- Appendicitis
- Renal Disease
- UTI
- Irritable bowel syndrome
Complications
- Diverticular abscess
- Systemically unwell, swinging pyrexia, palpable mass
- Perforation
- Generalised peritonitis
- Feculent peritonitis
- Fistula formation
- Colovesical = PUO, UTI in Male, Recurrent UTI in female, Pneumaturia
- Colovaginal (particularly common post hysterectomy) = Faeces PV
- Colocutaneous
- Fistula may be neoplastic in the context of diverticular disease
- Obstruction
- Secondary to : stricture formation, adhesion formation (prior surgery), occult neoplasm
- Haemorrhage
- May be occult
- entire colon may be full of blood
- the rectum alone may hold as much as 400mls of blood and clot before the urge to defecate is felt
- is an arterial bleed from damage to the nutrient vessels within the diverticulae
- may be very brisk (life threatening)
- ultimately 80% self-limiting
Management:
Acute (severe) presentation
- Follow ATLS guidelines
- ABCs
- Supplemental Oxygen
- IV access
- FBC/U&E/Coag
- Group and Cross Match 2 Units if actively bleeding
- IVF resuscitation
- IV Antibiotics
- Co-amoxiclav (Augmentin) 1.2g IV
- Metronidazole (Flagyl) 500mg IV
- ± Urinary Catheter to monitor urine output
- ± NG tube to rule out upper GI cause for bleeding
- Keep patient fasting ± theatre
Bowel rest - and - Antibiotics
Mild disease:
- Treat as an out patient
- Liquid diet for 7 to 10 days
- Analgesia broad spectrum antibiotics(metronidazole+Ciprofloxacin)
- Mandatory surgical OPD follow up
- Will need colonoscopy after few week
Referral
Wide degree of severity of presentations overall a diagnosis of exclusion
- Hinchey grade II or above
- Systemically unwell or measurable metabolic upset
- Alteration in more than one vital sign
- Clinical evidence of any complications of diverticulitis
- Intra abdominal Abscess, Perforation, Fistula
- Obstruction, Haemorrhage
- Unable to confidently exclude serious differentials
- Appendicitis, Colitis, Neoplasia
- Need for IV antibiotics
| Stage | Characteristics | |
|---|---|---|
| I | Pericolic Inflammation | Local lower left quadrant tenderness |
| II | Pericolic Intra abdominal retroperitoneal abscess | Local lower left quadrant tenderness |
| III | Generalised Purluent Peritonitis | Diffuse abdominal tenderness, rebound |
| IV | Generalised Feculent Peritonitis | Diffuse abdominal tenderness, rebound |
Pitfalls :
- A disease of the elderly who already have reduced physiological reserve
- Failure to recognize the significance of the possible blood loss or potential for blood loss
- ß blockade
- Regular Paracetamol masking pyrexia
- Right lower quadrant pain may be a redundant diverticular sigmoid colon
Prognosis
- Overall Mortality 1-5%
- Of complicated diverticulitis 15% percent require surgery
- 1/3 get better and become asymptomatic
- 1/3 get better but have non-specific symptoms
- 1/3 will have second episode
- Of those with a second episode up to 60% will experience complications
- Only 10% are asymptomatic following second attack
Hospitalisation also warranted:
- Unable to tolerate oral hydration
- Systemic signs such as fever,tachycardia etc. develop
- Immunocompromised patients
- Severe pain requiring IV analgesia
Discharge advice
- Complete course of antibiotics
- High Fibre Diet
- Long term Weight reduction, Exercise
- Return if symptoms do not settle
Surgery:
Usually do not perform endoscopy until 6 weeks post discharge
Usually will not make the diagnosis in the acute setting with a Ba Enema (risk of perforation and barium peritonitis)
Surgical options
- Order a CT !
- Percutaneous drainage of abscesses
- Surgical drainage of abscess
- Colonic resection
- Laparoscopic washout
References
- Cameron, J Ed. Current Surgical Therapy 8th Ed. Elsevier/Mosby Philadelphia PA : 2001
- Hinchey EJ, Schaal PGH, Richards MB. Treatment of perforated diverticulitis of the colon. Adv Surg. 1978;12:85-105.
- O'Sullivan G. et al. Laparoscopic Management of Generalized Peritonitis Due to Perforated Colonic Diverticula. Am J Surg. 1996;171:432-434.
- Russel R.C.G. ed Bailey and Love's Short Practise of Surgery 24th Ed Arnold London : 2004
- Shein, M. and Rogers P. Schein's Common Sense Emergency Abdominal Surgery 2nd Ed. Springer New York : 2005