B12. Diverticulosis and diverticulitis

Introduction

For introduction, epidemiology, etiology, and pathomechanism, see the corresponding pathology 2 topic.

Clinical features

Diverticular bleeding is one manifestation of diverticular disease. This bleeding may be occult (discovered by a screening test) or acute, manifesting as haematochezia. See topic A26.

Diverticulitis typically presents with left sided abdominal pain, especially in the left lower quadrant (the location of the sigmoid), and low-grade fever. The pain usually lasts for multiple days. Patients may also have nausea/vomiting or recent change in bowel habits.

Patients with complicated diverticulitis may present with ileus, colovesical fistula, haemodynamic instability, or downright shock. The patient will be peritonitic in the left lower quadrant.

Patients with diverticulitis have a high risk of recurrent bouts of diverticulitis.

Diagnosis and evaluation

CRP and WBC may be elevated in diverticulitis, but not always.

Abdominal CT with contrast is the first choice for imaging and to establish the diagnosis. CT will also show any complications of diverticulitis.

Hinchey classification of complicated diverticulitis

  • Stage I – Pericolic abscess
  • Stage II – Walled-off pelvic abscess
  • Stage III – Generalised purulent peritonitis
  • Stage IV – Generalised faeculent peritonitis

Treatment

Diverticular bleeding can be treated endoscopically during colonoscopy.

The treatment of uncomplicated diverticulitis is antibiotics and painkillers. Mild cases may be managed outpatient.

Complicated diverticulitis is treated according to the Hinchey stage. Hinchey I and II diverticulitis are treated with percutaneous drainage of the abscess, while Hinchey III and IV are treated surgically (usually with the Hartmann operation).

In the Hartmann operation, the diseased colon (usually sigmoid) is removed. The rectal stump is then oversewn, while a colostomy is formed for the proximal colonic stump. This colostomy may be reversed in the future (after months/year), when the proximal colonic stump and rectal stump may be re-joined.

All patients with diverticulitis should undergo colonoscopy after the acute illness, often 6 weeks later, to assess the extent of diverticulosis and to rule out malignancy.

No treatment can cure diverticulosis, but it’s important to prevent progression and recurrence with a high-fibre diet, weight reduction, etc.


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B14. Colorectal tumors

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