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Diverticular disease

  • Colonic diverticulae are outpouchings of colonic wall
  • Usually result from herniation of mucosa through muscular wall
  • Occur at sites where mesenteric vessels penetrate the bowel wall
  • Most common in sigmoid colon
  • Increased prevalence with age 
  • 10% population at 40 years
  • 60% population at 80 years
  • More common in developed countries

Aetiology

  • Due to lack of dietary fibre in Western diets
  • Low dietary fibre results in low stool bulk
  • Induces increased segmentation of colonic musculature resulting in hypertrophy
  • Increased intraluminal pressure results in herniation

Complications

  • Diverticulitis
  • Pericolic abscess
  • Purulent peritonitis - due to rupture of pericolic abscess
  • Faecal peritonitis - due to free perforation of diverticulum
  • Fistula - to vagina, bladder, skin
  • Colonic stricture

Perforated sigmoid diverticulum

Operative appearance of a colonic diverticulum

Picture provided by Josi Garcia, Tampico, Mexico

Diverticular perforation

Picture provided by Colm O'Boyle, Hull Royal Infirmary, United Kingdom

Investigation

  • Plain X-rays with positive diagnostic features (e.g. free gas, gas in bladder) are useful
  • Normal X-rays can not exclude complications of diverticular disease
  • Double contrast barium enema - allows diagnosis, assessment of extent and complications
  • CT +/- intravenous and rectal contrast - useful for imaging abscesses, fistulae

Treatment

  • Bowel rest by restricting oral intake and intravenous fluids
  • Intravenous antibiotics - 2nd generation cephalosporin (e.g. cefuroxime) and metronidazole
  • Active observation for the development of complications
  • If abscess formation - percutaneous drainage under radiological guidance usually possible
  • Subsequent elective resection and primary anastomosis often required

Bibliography

Ambrossetti P.  Diverticulitis of the left colon.  In:  Johnson C D,  Taylor I eds.   Recent advances in surgery 20.  Churchill Livingstone 1997:  145-160.

Ferzoco L B,  Raptopoulos V,  Silen W.  Acute diverticulitis.  N Eng J Med 1998;  338:  1521-1526.

McKee R F et al.  Radiological investigation in acute diverticulitis.  Br J Surg 1993; 80: 560 - 565.

Paterson-Brown S.  The use of laparoscopy in the acute abdomen.  Curr Pract in Surg 1993; 5: 207 - 210.

Simpson J,  Scholefield  J H,  Spiller R C.  Pathogenesis of colonic diverticula.  Br J Surg 2002;  89:  546-554.

Stollman N,  Raskin J B.  Diverticular disease of the colon.  Lancet 2004;  363:  631-639.

 

 
 

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