Diverticulitis
Diverticula
- Sac-like protrusions of mucosa through the muscular colonic wall.
- Predominantly occur in the sigmoid colon, except in Asian people where they can occur in the right colon.
Diverticulosis
- Diverticula are present without symptoms.
Diverticular disease
- Diverticula cause intermittent lower abdominal pain, without inflammation and infection.
Diverticulitis
- Diverticula become inflamed and infected, causing marked lower abdominal pain usually accompanied by fever and general malaise.
- Occasionally accompanied by large rectal bleeds
Presentation
Diverticular disease
- Intermittent pain in the lower abdomen, often in left lower quadrant
- Tender on examination.
- Pain may be exacerbated by eating, and may be relieved by the passage of stool or flatus.
- Constipation
- Diarrhoea
- Occasional large rectal bleeds.
- Bloating and the passage of mucus rectally
Diverticulitis
- Constant abdominal pain
- Severe and starting in the hypogastrium before localising in the left iliac fossa
- Guarding and tenderness in the left iliac fossa on examination
- Fever
- Alteration in bowel habits
- Dysuria and urinary frequency
- Large rectal bleeds (uncommon)
Differentials
Other abdominal causes:
- Irritable bowel syndrome.
- Appendicitis.
- Colitis.
- Bowel cancer.
Gynaecological causes:
- Pelvic inflammatory disease.
- Ovarian cyst.
- Ovarian torsion.
- Ectopic pregnancy.
Urological causes include:
- Urinary tract infection e.g pyelonephritis.
- Urinary tract obstruction e.g ureteric stone
Examination
- Abdominal rigidity, guarding, and rebound tenderness on examination due to perforation and peritonitis
- Abdominal mass on examination as a result of abscess formation
Laboratory investigations
FBC: Raised white cell count, C-reactive protein, or erythrocyte sedimentation rate, suggesting infection from diverticulitis
Radiological investigations to detect diverticulae
Barium enema
- Diverticuli
- Abscess
- Perforation
- Obstruction
- Fistula
Colonoscopy
- Single, multiple, or scattered diverticula, with or without acute mucosal inflammation
CT colonogram
- Thickening of bowel wall
- Masses
- Abscess
- Streaky mesenteric fat
- May show gas in the bladder in cases of fistula
Management
Diverticular disease
- Advise a high fibre diet
- Increase hydration
- Consider bulk-forming laxatives if dietary changes are not sufficient
- Paracetamol for pain relief if necessary - avoid prescribing nonsteroidal anti-inflammatory drugs and opioid analgesics (such as co-codamol) due to increased risk of diverticular perforation
Diverticulitis
- Prescribe broad-spectrum antibiotics to cover anaerobes and Gram-negative rods:
- Co-amoxiclav
- Treatment should last for at least 7 days
- Paracetamol for pain if required
- Recommend clear liquids only
- Gradually reintroduce solid food as symptoms improve over 2–3 days.
- Review within 48 hours, or sooner if symptoms deteriorate
- Start IV antibiotics if there is no improvement in 72 hours after oral antibiotics have been started or symptoms of acute diverticulitis
Recurrent diverticulitis
- Consider elective colectomy for recurrent disease
Complications
- Diverticular haemorrhage
- Bleeding occurs where the penetrating vessels responsible for the bowel wall weakness run over the diverticulum, making them vulnerable to injury.
- Bleeding is usually abrupt, painless, and large in volume.
- Bleeding stops spontaneously in 70–80% of cases.
- Dysuria and frequency, which may occur when inflamed bowel is in contact with the bladder.
- Perforation and peritonitis
- Abscess formation
- Fistula formation, most commonly to the bladder, but also to the vagina, skin, or another part of the bowel.
- Intestinal obstruction, from fibrosis and stricture formation following recurrent inflammatory episodes
Prognosis
- Most patients with uncomplicated diverticulitis recover following medical treatment and do not require surgical intervention
- Recurrent disease is associated with high mortality
page revision: 0, last edited: 09 Jun 2017 11:25