Diverticulitis

• Diverticulitis refers to inflammation and infection of diverticula.
• Diverticulosis refers to the presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms
• • Diverticulitis is caused by inflammation and infection of diverticula (outpouchings in the colon)
  • Most episodes occur on the left side of the abdomen and involve the sigmoid and descending colon
• The teniae coli do not surround the entire diameter of the colon, and the areas that are not covered by teniae coli are vulnerable to the development of diverticula.
• Diverticulosis is very common with increased age. Low fibre diets, obesity and the use of NSAIDs are risk factors. The use of NSAIDs increases the risk of diverticular haemorrhage
• Diverticulosis may cause lower left abdominal pain, constipation or rectal bleeding. Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided. Surgery to remove the affected area may be required where there are significant symptoms
• Diverticulitis refers to inflammation in the diverticula. Acute diverticulitis presents with:

  • Pain and tenderness in the left iliac fossa / lower left abdomen
  • Fever
  • Diarrhoea
  • Nausea and vomiting
  • Rectal bleeding
  • Palpable abdominal mass (if an abscess has formed)
  • Raised inflammatory markers (e.g., CRP) and white blood cells
• The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with:

  • Oral co-amoxiclav (at least 5 days)
  • Analgesia (avoiding NSAIDs and opiates, if possible)
  • Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
  • Follow-up within 2 days to review symptoms
• Patients with severe pain or complications require admission to hospital. Hospital treatment involves management as with any patient with an acute abdomen or sepsis, including:

  • Nil by mouth or clear fluids only
  • IV antibiotics
  • IV fluids
  • Analgesia
  • Urgent investigations (e.g., CT scan)
  • Urgent surgery may be required for complications
• Complications of diverticulitis include:

  • Abscess formation
  • Perforation leading to peritonitis
  • Sepsis
  • Fistulation
  • Bowel obstruction
  • Bleeding
• Diverticular abscesses can be managed medically with antibiotics, surgically or by radiological percutaneous drainage.
• Hartmann’s procedure

  This involves a sigmoid colectomy and the formation of an end colostomy. High risk procedure.
• Risk factors for diverticula:

  • Increased age
  • Low fibre diet
  • Diet high in red meat
  • Obesity
  • NSAIDs and steroids - risk of haemorrhage and perforation
• NSAIDs and opioids should be avoided in acute diverticular disease due to increased risk of perforation
• Signs and symptoms of acute diverticulitis that warrant hospital admission:

  • Abdominal mass or peri-rectal fullness (abscess)
  • Abdominal rigidity and guarding (perforation)
  • Signs of sepsis
  • Faecaluria, pneumaturia, passage of faeces through the vagina (fistula)
  • Signs of bowel obstruction
  • Dehydrated and can't manage fluids at home
  • Over 65
  • Significant comorbidity or immunosupression
• Clinical features of complications:

  • Tender mass, ongoing fever despite antibiotics
  • Perforation leading to peritonitis - severe abdominal pain, guarding, rebound and percussion tenderness
  • Sepsis - tachycardia, tachypnoea, hypotension, oligo/anuria
  • Fistulation - paecaluria, pyuria, faecal leakage through the vagina
  • Obstruction - inflammation leads to fibrosis and stricturing - abdominal pain, distension, vomiting and absolute constipation
  • Bleeding - rectal bleeding , can be life threatening and need transfusion
• Management of uncomplicated diverticulitis in the community:

  • Simple analgesia (avoid NSAIDs and opioids)
  • Safety netting
  • Co-amoxiclav for 5 days
  • Reassess patient within 48 hours
  • If having frequent or severe recurrent episodes refer to colorectal surgeons as OP
• Inpatient management:

  • IV fluids
  • IV antibiotics (usually Co-amoxiclav)
  • Analgesia
  • Surgery if medical management failed or complications occur e.g. fistula, abscess, obstruction and perforation
  • Purulent peritonitis - laparoscopic lavage or resection
  • Feculent peritonitis - colonic resection
  • Resection done with Hartmann's procedure
• Hartmann's procedure:

  • Emergency operation where pathology in descending or sigmoid colon or rectum is excised
  • Non anastomosis made as patients are very sick or have peritoneal contamination and anastomosis at risk of infection/not healing
  • Patient have an end colostomy and rectal stump (Hartmann's pouch)
  • If the patient recovers well they can have colostomy reversed and anastomosis at a later date (reversal of Hartmann's operation - very high risk)
• Most common types of fistula as a result of diverticulitis:

  • Colovesical (colon and bladder)
  • Colovaginal
• Diverticular bleed:

  • Normally occurs in the absence of diverticulitis
  • Diverticula result in weakening of adjacent vessel walls and if there is enough damage to the vessel wall it can bleed into the diverticulum and into the colon causing painless rectal bleeding
  • May need hospital admission if does not stop by itself