Diverticulosis, diverticular disease and diverticulitis

The prevalence of diverticula Is unknown as most are asymptomatic. However, it is rare before the age of 40 and increases with age.

For people with diverticulosis, the lifetime risk of developing acute diverticulitis is about 4–25%

Presentations

Diverticula are herniations of bowel mucosa through the bowel wall
DIVERTICULOSIS (or DIVERTICULAR DISEASE) simply means the presence of diverticulae
They can be present in any part of the gastro-intestinal tract but most commonly are found in the colon and, most commonly, in the left sided colon (sigmoid and descending colon)
Diverticular Disease tends to be asymptomatic and is relatively rare before the age of 40 although cases in younger patients are becoming increasingly common
Diverticulosis is present in around 80% of people aged 85 years and older

When diverticulosis becomes symptomatic. Symptoms may include:

Intermittent abdominal pain in the left lower quadrant: Pain may be triggered by eating and may be relieved by the passage of stool or flatus.
Tenderness in the left lower quadrant on abdominal examination.
Change in Bowel habit: Constipation, diarrhoea, or occasional large rectal bleeds.
Bloating and the passage of mucus rectally.

This is when diverticula become inflamed/infected (see image below) and can present with the following symptoms:

Constant abdominal pain: usually severe and starting in the hypogastrium before localising in the left lower quadrant, with fever.
- Note: in a minority of people and in people of Asian origin, pain may be localized in the right lower quadrant.
Tenderness in the left lower quadrant: palpable abdominal mass or distention on abdominal examination.
Change in bowel habit: and possible significant rectal bleeding.
Generalised symptoms: nausea, vomiting, dysuria, and urinary frequency.
PMH: diverticulosis or diverticulitis.

Rectal Bleeds: Occur in 15% of patients, 1/3 are massive, and 70-80% stop spontaneously
Intra-abdominal abscess formation: suggested by an abdominal mass on examination or peri-rectal fullness on internal rectal examination (for example due to a low-lying pelvic abscess).
Perforation and peritonitis: suggested by abdominal rigidity, guarding, and rebound tenderness on examination.
Sepsis: suggested by skin discolouration, raised or lowered temperature, rigors, change in conscious level or confusion, rapid pulse, and reduced urination.
Stricture: suggested by symptoms of colonic obstruction (colicky abdominal pain, constipation, vomiting, an inability to pass flatus and abdominal distension (beware the signs and symptoms of closed loop large bowel obstruction)
Fistula formation: the presence of faecaluria, pneumaturia, or pyuria may suggest colovesical fistula.

Noha Ahmed Nasef
/ Sunali Mehta

Bloods: VBG, FBC, U&E, CRP, Clotting, G&S (if bleeding), Culture (if requires IV Antibiotics)
Imaging:
- Erect CXR: if considering perforation (but remember this misses approx 25% of perforations)
- AXR: if considering obstruction
- CT Abdo/Pelvis: This may be the most appropriate 1st line modality if the patient is significantly unwell (liaise with the surgical team)

Complications of diverticulitis: Sepsis, Perforation, Peritonitis, Fistulae, Strictures, Obstruction
Significant rectal bleeding: for example, >200ml OR if the person is haemodynamically unstable
Severe Pain: that is uncontrollable with simple analgesia.
Dehydration: ensure IV fluids commenced
Requires IV Antibiotics (if needed) – Commence ASAP (<60min in Red-Flag Sepsis)
Frail or significant Co-morbidities

***If evidence of SEPSIS ensure SEPSIS-6 complete***

Oral antibiotics if there is suspected infection

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- If needed, prescribe at least one week of co-amoxiclav (or a combination of cefalexin with metronidazole or trimethoprim with metronidazole or ciprofloxacin and metronidazole if the person is allergic to penicillin).
Follow-Up (depending on severity)
- - Always contact the on-call surgical team for advice prior to discharge
  - Patient may require SDEC for repeat bloods
  - May require OP flexible sigmoidoscopy