Overview

• Implies inflammation +/- infection and is distinct from diverticulosis
• Rough incidence of diverticular disease is 50% at age 50yrs
• Although very common - the vast majory 80-90% remain relatively asymptomatic
• Commoner in countries with westernised diets
• Classically presents with LIF pain +/- PR bleeding +/- Pyrexia
• DDx is cancer of the colon – remember!
• On examination you must be thorough - obviously particularly the abdomen - are there any masses? DO NOT FORGET TO DO A PR

Clinical Features

• See perforated abdominal viscus
• LIF pain common, but site depends on where the disease is presenting in the colon (rare on right)
• Pain may be crampy +/- change in bowel habit
• Nausea and vomiting, constipation, diarrhea, flatulence, and bloating etc etc.....
• If perforation has occurred - seee perforated abdominal viscus
• Commonly tenderness in the area of the affected area (often LIF)
• In complicated with abscess formation, a tender palpable mass
• If a fistula forms, the Sx & Si depend on the site of fistula.

Staging

Several staging schemes available - the most useful is clinical staging by Hinchey's classification (as it can help dictate surgical intervention):

• Stage I - Small or confined pericolic or mesenteric abscess
• Stage II - Large abscess, often confined to the pelvis
• Stage III - Perforated diverticulitis causing generalized purulent peritonitis
• Stage IV - Rupture of diverticula into the peritoneal cavity with fecal contamination causing generalized fecal peritonitis

Initial Management

1. Check the WCC, HB & Amylase, other blood tests are only needed if medically indicated
2. Dipstick the urine and send some for culture
3. Place the patient on free fluids, no solid food, but enteral supplements can be used
4. Start IV Cefuroxime 750mg TDS + IV Metronidazole 500mg TDS
5. Get a plain AXR
6. Consider an early CT

Continuing Management

1. Patient can start ‘low residue’ diet as pain starts to settle and then goes onto ‘high residue’  (i.e. high fibre) when completely settled
2. Consider USS pelvis in women
3. Patients not settling after 48hrs need a CT abdo & Pelvis
4. Bowel needs to be imaged preferably by colonoscopy once the pain has settled.
5. The timing and need for surgical intervention is complicated and shouldbe discussed with the patients and a consultant colorectal surgeon:
   • Hinchey stage I may be treated medically without surgical intervention
   • Hinchey stage II may be treated by radiological drainage and medical treatment
   • Hinchey stage III/IV disease almost always requires surgical intervention
6. Elective surgery previously recommended in those who had 2 or more episodes of diverticulitis successfully treated medically; however, recent data call this practice into question when the patient is otherwise healthy - this very much depends on the patient and requires in-depth discussion and should be made on a case-by-case basis.
7. A 2-stage surgical approach is the most common & safest surgical procedure:
   • Hartmann's procedure with reversal 3-6 months later. This is the preferred & recomended approach in patients with faecal peritonitisand sepsis.
   • The alternative is resection of the diseased colon, primary anastomosis and proximal diverting stoma - this is for experienced surgeons only who can make the correct decision to perform this based on intr-operative findings - it is not recomended in faecal peritonitis
8. There is no role for lavage and drainage as morbidity and mortality are significantly higher