DIVERTICULAR
DISEASE
Overview
• Acquired condition mostly in the
colon
• Associated with ‘western diet’
• Present in >60% of over 70s
• Mostly asymptomatic but:
– Change in bowel habit
– Abdominal pain
– Rectal bleeding
Anatomy
• From deverticulum – “off the main track”
• Anywhere from oesophagus to colon
True
False
Pathogenesis
• Peristalsis requires smooth muscle contraction
• Exaggerated or abnormal contraction causes high-pressures on
walls
• High pressure causes herniation
Pathogenesis II
• Higher pressure in smaller tube
• Sigmoid colon is narrowest
• Weaker where blood vessels traverse the
muscle layer
Risk Factors
• Strong
– Age > 50 years
• Moderate
– Low dietary fibre
• Weak
– “Western diet”
– Obesity
– NSAID use (associated with symptoms)
Signs and Symptoms
Diverticulosis
Diverticulitis
Presence of diverticula
Inflammation of diverticula
Usually asymptomatic
Pain (commonly LLQ)
Discomfort / change in bowel habit
Fever
Bleeding (often painless)
Not associated with bleeding
Bloating
Tenderness + guarding
Complications
• Fistulae
– Colovesical
– Colovaginal
• Abscess
• Perforation
– Hinchey I to IV
• Strictures
– Obstruction
Differential Diagnosis
•
•
•
•
•
•
•
•
Colorectal cancer
Appendicitis
IBD
Pyelonephritis
Ischaemic colitis
Pelvic inflammatory disease
Irritable bowel syndrome
Pancreatitis
Investigations
• Bloods:
– FBC: raised WCC and neutrophilia
• Imaging:
– Abdo XR
– CT abdomen
– CXR / USS if CT cannot be obtained
• Interventional:
– Colonoscopy / sigmoidoscopy (if suspicious
Management
• Asymptomatic
– No treatment required
• Symptomatic diverticular disease
– Dietary modification and fibre supplementation
– Oral co-amoxiclav (500mg oral 8-hourly for 7 days)
• If evidence of infection
– Bleeding: consider endoscopic haemostasis
Management II
• Symptomatic diverticulitis
– Pain relief (WHO analgesic ladder)
– Oral antibiotic therapy
•Co-amoxiclav 500mg 8-hourly for 7 days OR,
•Ciprofloxacin AND metronidazole for 7-10 days
– Temporary low-residue diet (i.e. foods low in
• Recurrent diverticulitis / fistulae
– Elective colectomy
Management III
• Diverticular abscess (> 3cm or refractory to antibiotics):
– Analgesia
– Radiological drainage or surgery
– IV piperacillin/tazobactam
• Peritonitis:
Hinchey stage
Findings
Management
I
Pericolic abscess
IV antibiotics
II
Distant abscess
IV antibiotics and drainage
III
Purulent
peritonitis
Left colectomy, laparoscopic lavage and
drainage, or Hartmann’s procedure
IV
Faecal peritonitis
Hartmann’s procedure
Questions?