Diverticular diseases
- Includes a spectrum of conditions
- Asymptomatic vs symptomatic
- Acute vs chronic
- Complicated vs non complicated
Diverticulosis:
- Small pouches due to herniation of the mucosa into colonic wall
- Commonest pathology responsible for lower GI bleeding
- False diverticula
- Inflammation of diverticula, due to obstruction by fecalith
- Usually affects elderly
- 20% of patients with diverticulitis are younger than 50 years.
- In chronic form, patients may have recurrent low-grade diverticulitis.
Signs and symptoms
Depends on the location, the severity of the inflammatory process, and the presence of complications.
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Abdominal pain:
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Left lower quadrant: (70% of patients), as most diverticula occur in the sigmoid colon
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Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-sided diverticulitis
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Change in bowel habits
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Nausea and vomiting
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Constipation
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Diarrhea
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Flatulence
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Bloating
| Complication Category | Specific Complication |
|---|---|
| Inflammation | Peri-diverticulitis |
| Pericolic abscess | |
| Purulent peritonitis | |
| Faecal peritonitis | |
| Inflammatory mass | |
| Portal pyaemia | |
| Obstruction | Fibrotic stricture |
| Adherent small bowel loops | |
| Bleeding | Massive lower Gl haemorrhage |
| Chronic intermittent blood loss | |
| Anaemia | |
| Fistula formation | Colovesical fistula |
| Colovaginal fistula | |
| Enterocolic fistula |
Diagnosis
- Usually made on the basis of history and physical examination,
Laboratory tests :
- CBC: high WBC, Hb,
- Electrolytes,
- Renal function,
- LFT
- Urinalysis / culture
- Blood cultures
- Pregnancy test
Radiology images:
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Plain abdominal radiograph series
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Contrast enema, * Water-soluble medium, * Mild-to-moderate uncomplicated cases
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CT abdomen with contrast * Best imaging method to confirm the diagnosis. * Sensitivity and specificity 97% * Bowel wall thickening * Soft-tissue inflammatory masses * Complications, exclude other pathology
Hinchey’s classification for complicated cases:
- Clinical staging
- To chose the proper management option
| Hinchey Grade | Description |
|---|---|
| I | Localised para-colonic abscess |
| II | Distant abscess (e.g. pelvic, sub-phrenic) |
| III | Purulent peritonitis |
| IV | Faecal peritonitis |
Management:
- Conservative: (mild cases) * Initiate bowel rest and intravenous fluid hydration * Broad-spectrum intravenous antibiotic Within 2-3 days of hospitalization, fever, pain, and leukocytosis should begin to resolve * Start on a clear liquid diet and advanced as tolerated * CT-guided percutaneous drainage
Surgical intervention:
- Hinchey’s stage III or IVZ
- Complications
- Inability to rule out carcinoma
- Failure of medical therapy
