Diverticular disease of the colon

-Diverticular disease is the most common structural abnormality of the colon.

– A true diverticulum is a saclike herniation of the entire bowel wall, whereas a pseudo diverticulum involves only a protrusion of the mucosa and submucosa through the muscularis propria of the colon

-In Western countries, diverticula are predominantly left-sided, 95% involve the sigmoid colon while in the Eastern countries, they are predominantly right-sided.

only 20% of patients with diverticulosis develop diverticular disease

-the rectum is always spared

Uncomplicated Diverticulosis

-The majority of patients with diverticulosis are asymptomatic

Treatment: Most patients with diverticulosis do not require any specific treatment.

There are no medical treatments that will lead to the regression of diverticula, once present.

Asymptomatic diverticular disease is best managed by lifestyle changes. Recommend a high-fiber diet or fiber supplements such as psyllium or methylcellulose.

Refrain from smoking

Q: How does a high-fiber diet help in diverticular disease?

Fiber is fermented by gut bacteria producing fatty acids and gas. This results in shortened gut transit time and reduced intracolonic pressure.

Q: What is the most common location of diverticular disease? Sigmoid colon

Diverticulitis

Diverticulitis is inflammation of a diverticulum.

Symptoms & Signs:

Symptomatic Uncomplicated Diverticular Disease, SUDD: Fever, anorexia,leukocytosis, left lower quadrant abdominal pain, and obstipation

Complicated diverticulitis: Symptoms and signs listed above plus symptoms and signs associated with an abscess or perforation  and less commonly with a fistula.

Diagnosis:

Colonoscopy is relatively contraindicated in patients in whom acute diverticulitis is suspected, due to an increased risk of colonic perforation.

The diagnosis of diverticulitis is best made on CT: the presence of colonic diverticula and wall thickening, pericolic fat infiltration, inflammation within the pericolic fat,  abscess formation, or extraluminal air or contrast suggests diverticulitis.

Treatment:

Mild disease: clear liquid diet, selective use of antibiotics – augmentin, metronidazole + ciprofloxacin, rifaximin. Mesalamine to decrease inflammation.

Severe disease: nothing  by mouth, IV fluids, IV antibiotics

Antibiotics: oral penicillin/clavulanic acid, third generation penicillin such as piperacillin, third generation cephalosporin, ciprofloxacin and metronidazole.

A colonoscopy should be performed ~6 weeks after an attack of diverticular disease.

Prognosis: diverticulitis may lead to abscess formation which may lead to fistula formation

Q: What is the most common symptom of diverticular disease? Abdominal pain, usually localized in the left lower quadrant.

Q: Why is endoscopy contraindicated during the initial stages of an acute attack of diverticulitis? Because of the risk of free perforation.

Q: How do you differentiate severe diverticulitis from ulcerative colitis? Rectum is spared in Diverticular disease

T or F? Diverticulosis is not associated with an increased risk of colorectal cancer. True

Q: What do you suspect in a woman, who has a history of diverticular disease and hysterectomy, and reports passing gas or stool through her vagina? Colovaginal fistula

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