Mohd Syafiq Bin Shahbudin 06-06-102
Introduction
Diverticular disease occurs when pouches (diverticula) in the intestine, usually in the colon, become inflamed. It is classified into diverticulosis and diverticulitis.
Patients Manifestations
In uncomplicated cases
Diverticula usually Asymptomatic. However, the symptoms may do appear in form of:
left lower quadrant pain (70%) fever and localized tenderness nausea vomiting irregular bowel movements bloating
Emergent cases fistulation Perforation & Peritonitis
Etiology & Risk factors
Factors increase the risk of developing diverticular disease:
Advanced age (more than half of people over age 70 have
the condition) Low fibre diet Obesity Male gender, for diverticulitis
Investigation
Laboratory evaluation
CBC shows leukocyctosis. Hb level in patient
with hematochezia.
Urinalysis RBC/ WBC in patients urine with
a colovesicular fistula. To distinguish sterile pyuria dt diverticulitis from the fistula.
Liver and Renal Function test Others
Imaging studies
Abdomen X-Ray
Demonstrate bowel obstruction +ve free air indicate perforation.
Abdominal CT helical CT and colonic contrast.
Sigmoidoscopy is contraindicated in early case.
Management
Uncomplicated diverticulosis
Patient get benefit from high fiber diet. American Dietatic Association recommends consuming 20-35gram fiber/day to improve bowel habit.
Diverticulitis
Need to be hospitalized for preoperative diagnosis Bed rest Nothing by mouth and/or NS suctioning. IV fluid
Broad spectrum Antibiotic
Surgery if perforation, abscess or neoplasm suspected. In
emergency surgery, patient may require a temporary colostomy bag.
Complicated / Emergency management 1) GI bleeding/hemorrhage
Diverticular bleeding is the most common cause of lower
GI bleeding in adult.
Bleeding in formed of massive and painless rectal
hemorrhage.
Non surgical management Resuscitative measures including airway maintenance,
supplemental oxygen, measurement of hemoglobin and hematocrit level.
Intravenenous fluid replacement should begin to restore
circulation by using normal saline/lactated ringers solution. If bleeding persist, packed RBCs is given.
Diagnostic workup should begin with colonoscopy. Injection with epinephrine or electrocautery treatment.
Endoscopically placed clips (endoclips), fibrin sealant, and
band ligation may also be helpful.
radionuclide imaging with a technetium-99mtagged red
blood cell scan
Arteriography may be needed if the lesion is still not
identified.
Selective
embolization, intra-arterial vasopressin infusion, surgery, or other therapeutic modalities should be considered
Surgical modality
Indication for surgery: 1) Large transfusion requirement >4packed RBCs within 24hours. 2) Recurrent hemorrhage refractory to tx. 3) Hemodynamic instability despite meds tx.
Hartmanns prodecure - Resection of rectosigmoid with
closure of the rectal stump and formation of an end colostomy.
To prevent the progression of diverticular disease, fibre
supplementation (32 g/day) and increasing levels of physical activity may be helpful.
2. Intestinal perforation - Hartmanns procedure that include temporary colostomy is the treatment of choice. Fluid and electrolyte management as well as antibiotics are essential adjuncts. 3. Intestinal obstruction Initial manage similar to uncomplicated diverticulitis. 4. Mal-absorption Due to bacterial overgrowth. Treat with antibiotic.
