2.20. Colon diverticulosis, diverticulitis (symptoms, diagnosis, conservative treatment, surgical indications)

What are diverticles

outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon

Existance of diverticulas- not a disease

What are the predisposing factors

• high intraluminal pressure

• lack of enough fibres

• low stool volume

• elongated transit time

• NSAID 

• smoking- more frequent complications

• low physical activity

• obesity- more complications- bleeding

• alcohol intake

• microbiome

What is diverticulitis

Inflammation in the peridiverticular fat

What are the types of diverticulitis

• Acute, uncomplicated → inflammation without perforation or abscess

• Acute, complicated → disturbed integrity of bowel wall → Hinchey classificaiton

  • Chronic diverticulitis → steatosis, fistulas

  • Diverticular bleeding

What are the symptoms of acute, uncomplicated

• left lower abdominal pain

• bloating

• change in stool habits

What are the complications of diverticulitis

• Bleeding

• Abscess

• Perforation

• Peritonitis

• Fistula

• Stricture

How do you check for diverticular bleedings

Colonoscopy, CT, angiography

How do you diagnose diverticulitis

• Anamnesis

• Physical exam

• Lab

  • ESR, CRP >170, leukocytosis

• Imaging

  • US, CT- gold standard

What is the Hinchey classification

Classification to grade the severity of acute diverticulitis

• Stage 0

  • thickened bowel wall

• Stage 1a

  • Periocolic mesenteric infiltration

• Stage 1b

  • Pericolic/ mesocolic small <4cm abscess

• Stage 2a

  • Larger abscesses without free air, often confined to pelvis

• Stage2b

  • with free air

• Stage 3

  • Perforated diverticulitis

  • when peridiverticular abscess has suptured in purulent peritonitis

• Stage 4

  • Ruture of uninflamed and unobstructed diverticulum into free peritoneal cavity with fecal contamination- free rupture

What is the medical treatment for D. without complications

• Dietary restriction and bowel rest

• Antibiotics

  • Monotherapy- metronidazole or ampicillin-sulfbactam, ampicillin-clavulic acid, clindamycin, tazobactam, cefalosporin

  • Combination- ciprofloxacin- metronidazole

What is the medical treatment for recurrent D

• colonic diverticulitis without abscess or perforation alone is not always an indication for colectomy

• Prevent recurrence

  • lifestyle- smoking cessation, less meat, more physical activity, weight loss

  • Drugs- probiotics

Which stages require antibiotic treatments

• Stage 2a

• 2b

• 3

• 4

What is the therapy for abscesses

• <3cm- antibiotic therapy and bowel rest

• 3-5cm- individualised treatment based on state of disease, ability to drain

• >5cm- US or CT guided drainage, antibiotic therapy, bowel rest be instituted

What are the indications for surgery

• 11% malignancy in complicated D-colonoscopy at week 6th

• Elective- considered after complicated 1b, abscess >5cm, 

  • recurrence rate 60-70%

• Fistula, obstruction, bleeding- elective 1B

What is the emergency surgery

Recommended for colonic diverticulitis in patients presenting with generalised peritonitis

What are the indications for colectomy

when antibiotic therapy and drainage are ineffective

What are complicated colonic diverticulitis with fistulas

Formation of fistulas between colon and other organs due to diverticula

Colectomy is recommended

Why do strictures form

Due to colonic diverticulitis- colectomy recommended for stricture that develop after remission of colonic diverticulitis