- 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
- 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.
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
- Check the WCC, HB & Amylase, other blood tests are only needed if medically indicated
- Dipstick the urine and send some for culture
- Place the patient on free fluids, no solid food, but enteral supplements can be used
- Start IV Cefuroxime 750mg TDS + IV Metronidazole 500mg TDS
- Get a plain AXR
- Consider an early CT
- Patient can start ‘low residue’ diet as pain starts to settle and then goes onto ‘high residue’ (i.e. high fibre) when completely settled
- Consider USS pelvis in women
- Patients not settling after 48hrs need a CT abdo & Pelvis
- Bowel needs to be imaged preferably by colonoscopy once the pain has settled.
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
- 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.
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
- There is no role for lavage and drainage as morbidity and mortality are significantly higher