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Diverticular disease


Diverticular disease


Diverticula are herniations or small pouches in the mucosal lining of the colon , most commonly affecting the descending and sigmoid colon
 ( Amerine , 2007 ; Marrs 2006 )

protrusion occurs in weak areas of the bowel through which blood vessels can penetrate ( see figure ) diverticula generally are multiple typically 5-10 mm in dia but can occasionally be up to 20 mm most common site is sigmoid colon ( 90 % ) , although can happen throughout the large bowel can also happen on right side result possibly from complex interaction of colon structure , intestinal motility , diet and genetic features

Distribution -Sigmoid involvement ( 95 % ) Sigmoid alone ( 65 % ) Entire colon ( 7 % ) Located near sigmoid ( but with a normal sigmoid ) in 4 %

Most frequent finding in colonoscopies done to r/o cancer Frequent in Western countries – affecting up to 50-66 % individuals aged > 80 Prevalence is increasing worldwide ( ↑↑es with urbanization ) Increases with age ( uncommon < 40 ) Exact incidence is difficult to ascertain as most patients are asymptomatic and studies are usually retrospective Clinically and economically – most significant disease in gastroenterology

Risk factors –Low fiber diet Age > 50 yrs Western diet ( for eg diet high in red meat and total fat content ) Obesity NSAIDs use No current link identified with smoking , caffeine and alcohol consumption Genetics- rare syndromes demonstrate a strong predisposition of colonic diverticula . Examples include
○ Marfans syndrome
○ Ehlers-Danlos syndrome
○ Polycystic kidney disease ( PKD )

differential –Carcinoma of the bowel Appendicitis Inflammatory bowel disease Ishcaemic colitis , Pelvic inflammatory disease Pyelonephritis UTI

Diverticulosis –Asymptomatic diverticula Usually an incidental finding Current consensus does not advice treatment or monitoring Role of dietary fiber not established to reduce the risk of developing diverticular disease No treatment indicated

Diverticular disease- Also defined by terms as
 symptomatic diverticula symptomatic diverticular disease symptomatic uncomplicated 
diverticular disease ( SUDDP )Intermittent abdominal pain – 
left lower quadrant Pain may be triggered by eating Constipation , diarrhoea or occasionally large PR bleed Bloating Presentation may be similar to Irritable Bowel Syndrome Tender LLQ on palpation

Refer if suspected Investigations 
○ colonoscopy
○ CT Give advise on
○ diet-healthy balanced diet
○ Fibre intake up to 30 gm/day Consider a bulk forming laxative if
○ unable to take high fibre diet
○ symptoms of diarrhoea / constipation persist Analgesia 
○ prn paracetamol
○ CKS advises caution with the use of 
Codeine.Consider a follow up in 1 month based on clinical judgement

Diverticulitis-About 4 to 5% of patients with colonic diverticula develop acute diverticulitis Diverticulitis represents a spectrum of inflammatory changes which can range from
○ subclinical local inflammation
○ generalized peritonitis with free perforation Underlying process is thought to be a micro or macro perforation of a diverticulum due to
○ increased intraluminal pressure
○ inspissated food particles
○ thickened fecal material ( as in appendicitis ) in the neck of diverticulum.

Presentation-Severe constant abdominal pain starting in the hypogastrium which then localizes to the left lower quadrant Change in bowel habit PR bleed ( can be significant )
most common cause of lower GI bleed in the elderly Nausea , vomiting , dysuria and urinary frequency Fever Leukocytosis

Admit if –suspected complication symptoms cannot be managed in primary care eg severe abdominal pain Risk of dehydration and unable to tolerate oral fluids Unable to take/ tolerate oral antibiotics Frail , sig co-morbidities , immunosuppression

Manage in primary care –Mild , uncomplicated case Consider antibiotics 7-14 days if infection suspected
○ augmentin
○ metronidazole
○ ciprofloxacin watchful waiting if
○ no infection suspected
○ no comorbidities
○ systemically well Check bloods for ↑ WCC, CRP Advice clear liquids for 2-3 days with reintroduction of solids if symptoms improve

Complications- Complete bowel obstruction due to diverticular disease is relatively rare
Partial obstruction is more common Intra-abdominal abscess -mass on O/E or peri-rectal fullness on DRE Perforation ( free perforation ) uncommon
More likely if immunocompromised 
Associated with high mortality rate Fistulas- occur in 2 % of patients with divertiucular disease
↑↑ frequent in men ( mostly colovesical ) Bleeding – approximately 15 % of people with diverticula will develop bleeding from the bowel wall
usually abrupt , painless and large in volume

References- References
 Commissioning guide : colonic diverticular disease Royal College of Surgeons ( RCS ) March 2014 World Gastroenterology Organisation Practice guidelines Diverticular Disease Dr T Murphy et al Diverticular Disease : Diagnosis and Treatment Holly Salzman et al American Family Physician Oct 2005 Vol 72 , Number 7 REVIEW Treatment of diverticular disease : an update on latest evidence and clinical implications Carobotti M, Annibale B. Drugs in Context 2018 ; 7:212526 BMJ Best Practice Diverticular Disease Böhm SK. Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking. Viszeralmedizin. 2015;31(2):84-94. Sartelli M, Catena F, Ansaloni L, et al. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg. 2016;11:37. Published 2016 Jul 29. doi:10.1186/s13017-016-0095-0 Diverticular disease- CKS NHS

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