Diverticular Disease

Diverticulosis is defined as the outpouching of the mucosa and submucosa through the muscularis propria (false diverticulum since only 2 layers are involved). This is a very common condition in the western world, especially among older patients. However, diverticulosis are increasing found in younger patients.

Etiology and risk factors /association:

• Diverticulosis is believed to be related to wall stress: They arise where the vasa recta traverse the muscularis propria (which is a weak point in colonic wall). The sigmoid colon is most commonly affected. If bleeding is present, usually from the left colon but more common in asian population. If bleeding more likely from the left colon.
• Associated with constipation, straining, Low fiber commonly seen in older adults.
• Lack of dietary fiber lead to sustained bowel contraction and increase intraluminal pressure causing herniation of colonic wall at weak spots like (vasa recta traverse regions)

Symptoms and Clinical Presentation:

• Mostly No Symptoms
• Sometimes LLQ (left lower quadrant) abdominal pain colicky (Asian RLQ), Constipation, Hematochezia (left lesion)
• Some progress to Diverticulutis (infection) which fever LLQ pain/tender, fever with leukocytosis.
• Sometimes even palpable mass

Diagnosis:

• Most accurate test is Colonoscopy for diverticulosis.
• Most accurate is CT scan for diverticulitis (never use colonoscopy, enema for diverticulitis)
• Flask like structures (95% sigmoid colon) of mucosal are outpouching from lumen through muscular layer. Another thing with flask morpho: amoebic colitis have flask shaped ulcers.

Complications:

• Bleeding (hematochezia), Diverticulitis (see below) never enema or scope because can perforate and inflammation weakens the colonic wall.

Treatment and Management

• Increase fiber in diet + products like (Metamucil, bulking agents) all decrease progression to inflammation.

DIVERTICULITIS

Diverticulitis is defined as inflammation of the diverticulosis, usually from infection secondary to fecal impaction. Diverticulitis is by default (micro-perforation). This is a complication of diverticulosis due to infection with GI bacteria.

Symptoms and Clinical presentation:

Left lower quadrant (LLQ) abdominal pain that is more intense; tenderness, fever, leukocytosis and sometimes a palpable mass. In asian population, the lesion is more commonly right sided and thus, make sure to include in your differentials and workups.

Diagnosis of diverticulitis:

CT abdomen is the most diagnostic scan to do for a patient with suspected diverticulitis. It is important to note that colonoscopy, enema, should never be done on a patient suspected of diverticulitis.  Patient usually have fever, leukocytosis, tenderness.

Complication of diverticulitis:

• Abscess, Fistula – Inflamed diverticulum ruptures and attaches to a local structure (e.g. colovesicular fistula presents with air/stool in urine!) fistula with bladder.
• Obstruction – Chronic inflammation with thickening of bowel wall.
• Perforations (abscess and peritonitis) (Contraindicated to scope/enema for diverticulitis)

Treatment and Management of Diverticulitis

• NPO (bowel rest) is very important!
• Antibiotics that cover E.coli and Anaerobes
  • [Ciprofloxacin + Metronidazole] OR [Cefotetan/cefoxitin + Gentamicin]  OR
  • Augmentin / Zosyn / Cabapenem
• Surgery if following occurs
  • No response to therapy; Frequent recurrence
  • Perforation, Fistula formation, Abscess, Strictures, Obstructions (complication of diverticulitis)