DIVERTICULITIS

• Presence of diverticula (plural diverticulum) – pouches protruding outwards from the large intestine wall – small mucosal herniations protruding through intestinal layers and smooth muscle

• Intermittent pain in lower left quadrant (with constipation, diarrhoea, rectal bleeds) • Abdominal pain worsened by eating, relieved by passing stool or wind • Flatulence • Lower left quadrant tenderness on palpation ( R-S= Asian population)

• Symptoms can overlap with other conditions, such as IBS • No systemic symptoms

• Diverticulosis – condition where uninflamed diverticula – Usually asymptomatic

– symptomatic

Condition where one or more inflamed/infected diverticula

• Diverticular disease is very common, particularly in industrialised countries – Westernisation increases incidence – Lack of fibre

– similar in males and females – increases with age – rare in people aged <40 years – 1/3 people >65 years, >65% people >85 yrs

80-85%

Approx 5% of patients with Diverticulosis develop Diverticulitis

15-25% Mortality associated with these – Abscess formation – Intestinal rupture – Fistulas (inflammation/abcess causes passageway) – Peritonitis (lining abdominal wall and organs in abdomen) – Massive bleeding • More common in patients • Immunocompromised • Anti-inflammatories • Severe co-morbidities

– Genetics: * Left-sided diverticula predominate in the west (sigmoid colon) * Right-sided predominant in Asians – Dietary factors: * Associated with a low fibre diet and constipation * Associated with obesity

– Increased intraluminal pressure and weakening of muscle wall thought to be a primary cause – Abnormal colonic motility – Defective muscular structure – Changes in collagen structure eg in aging

• Colonic muscular hypertrophy results in narrowing of lumen and formation of small chamber with high pressure and subsequent diverticula

• Faecal material or undigested food collect in diverticula and cause obstruction • Mucus secretion and normal bacterial overgrowth lead to distension of diverticula • Results in vascular compromise and perforations • Increase in intraluminal pressure and stuck food particles may also damage diverticula wall, resulting in inflammation and necrosis and perforation • Recurrent attacks lead to scar tissue formation and lumen narrowing

• Asymptomatic • No need for routine follow ups • Maintain healthy balanced diet, high in fibre • Maintain adequate fluid intake • If overweight, advise about benefit of weight loss, exercise and also smoking cessation to prevent progression. • If constipated-offer bulk forming laxatives

• High fibre diet • Bran supplements/Bulk-forming laxatives • Lifestyle advice as per diverticulosis • Anti-spasmodics when colic eg alverine, mebeverine, peppermint oil etc

• Avoid NSAIDs • Anti-motility drugs to slow transit time eg codeine and loperamide should NOT be used • Risk of diverticular perforation

• Constant lower left abdominal pain with: • Fever • Sudden bowel change • Blood/mucus in stools • Lower left quadrant tenderness • Palpable abdominal mass/distension • Malaise • N&V • Increased WBC, if bleeding occurs, increased platelets, anaemia, increased CRP

• Refer for hospital assessment if: • Patient > 65 years *Co-morbidities/ Immunosuppressed • Can’t take oral Abx at home • Dehydrated/at risk, can’t rehydrate sufficiently from home • Uncontrollable abdominal pain plus signs of complicated acute diverticulitis:

• Intra-abdominal abscess (mass on examination) • Diverticular haemorrhage • Peritonitis (rigidity/guarding upon examination) • Stricture (reduce GI motility, constipation, cramping) • Fistula formation (faecaluria, pneumaturia, passing faeces through vagina) • Intestinal obstruction (cramping, absolute constipation, distension) • Sepsis ( Increased resp, Increased HR, Decreased systolic BP, no urine output, skin discolouration, cognitive impairment

• Co-amoxiclav 500/125 TDS x 5 days (Cefalexin if penicillin allergy) + Metronidazole 400mg TDS x 5 days , OR • Trimethoprim 200mg BD x 5 days + Metronidazole 400mg TDS x 5 days

• Consider no Abx strategy (antimicrobial stewardship) • Analgesia e.g. Paracetamol (avoid NSAIDs/opioids) • Re-present if symptoms worsen