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home - Colon - Miscellaneous - Diverticula Written by Dr Sebastian Zeki
Methods GMP
Knows the physiology of intestinal absorption, secretion and motility SCE 1
Understands the biochemical processes occurring within the gut
lumen and at mucosal level

Has awareness of the factors controlling these processes – in
particular the neuro-endocrine influences

Understands the range of mechanisms by which diarrhoea can result
from disturbances in each of these processes

Knows the causes of both acute and chronic diarrhoea
Knows the range of investigations appropriate to determining the
cause of the patient’s diarrhoea and is aware of the range of
therapeutic possibilities

Makes a detailed clinical assessment of patients that present with
either acute or chronic diarrhoea

Recognises the potential need for urgent fluid replacement CbD,
Makes appropriate use of microbiology and other relevant laboratories in reaching a diagnosis

Shows ability to interpret results, reach a diagnosis and formulate a
treatment plan

Reacts appropriately to the urgency of the clinical presentation
Always shows sympathy and understanding especially when the
patient is distressed


Complicated (25%) Obstruction- Obstruction is rarely complete. 20% Diagnosis:Endoscopy and ba enema; CT (V. se and sp).Cystoscopy can be useful. Diverticular fistulaeColovesical fistulas (65%).Colovaginal fistulas (25%).Coloenteric and colouterine fistulas. Uncomplicated (75%) 1/3rd asympto-matic 1/3rd abdo episodic cramps 1/3rd get 2nd episode diverticulitis Findings:Local colonic thickening next to inflamed bladderDiverticulae;Air and oral contrast in bladder. Diverticular colitis Endoscopy: Sigmoid segmental colitis.From mild inflammation + submucosal hemorrhages (peridiverticular red spots on colonoscopy ="Fawaz spots") to IBD type inflammationCause may be related to mucosal prolapse, fecal stasis, or localized ischaemia. 10% symptomatic,90% asymptomatic Bleeding and diverticulitis don’t co-exist usually Uncomplicated Diverticulitis Treatments:Bowel rest and antibiotics-successful in 80%.High fibre diets: Can prevent recurrence.Avoid Seeds and nuts : No value.Colonoscopy after 6 weeks (for other pathology.) Diverticular abscessAbscesses occur in 16% of patients with acute diverticulitis without peritonitis and in 45% % of those requiring surgery for diverticulitis.Treatment involves percutaneous drainage. Leave in until < 10 mL/ 24hrs.Small abscess do well with antibiotics alone and have similar outcomes to uncomplicated divertular disease. Tx: Sigmoid colectomyDiverticular fistulas do not generally close spontaneouslyUsually treat with an elective one-stage procedure with resec-tion and primary anastomosis.Observation appears safe in patients with C/I to surgery. Mild - Pain and inc WCC Moderate - Pain/inc WCC/vomiting Severe - As above plus peritonitis Investigations - CT if toxic/mass/peritonitic Prognosis After first attack - 1/3 asymptomatic,1/3 episodic discomfort,1/3 further episodeSpecial Considerations:-Young patients:Usually obese males- not worse disease,so can wait before they have an operationImmunosuppression (chemo/steroids/diabetes/renal failure/collagen vascular disorders) — Inc. perforation rate. Consider surgery after single diverticulitis episodeProbably not the case in HIV or those on chemo as would interupt chemo regimeRight-sided diverticulitis — 20% of diverticulae and 75% of diverticulitis in Asians.No consensus on what to do for this lot DiverticulitisErosion and necrosis of diverticulae by inspissated food particles.Investigation: CT. Bleeding 25% Half right sidedRisk factors for bleeding Lack of dietary fiber;NSAID use ;Old age;ConstipationStops spontaneously in 75% Stops in 99% transfused <4U/day.20% rebleedRisk of more bleeding= 35%Surgery in 5% Diverticular Disease 3 Main symptomatic outcomes Perforation Diverticulitis is the most common cause-M>F; uterus protects bladder from inflamed sigmoid Written by Dr Sebastian Zeki Clinical Manifestations:Asymptomatic or haematochezia and abdominal pain.Treatment1. High fibre diet, antibiotics and/or aminosalicylates if sx2. Combination therapy with oral beclomethasone dipropionate plus VSL#3 (probiotic)