QuestionSBA
QuestionChoice
Abdominal x-rays may be useful to rule out bowel obstruction (dilated bowel loops) and perforation (Rigler sign) if these were within the differentials. It would not be able to identify the cause of this patient's presentation, however, with no clinical features to suggest perforation or obstruction in this case.
53168
b
Abdominal X-Ray
QuestionChoice
This patient is at high risk of diverticulitis given the presence of left lower quadrant pain, fever, and history of constipation. CT abdomen is the gold standard for diagnosis. Diverticulitis occurs when diverticulae (outpouchings of bowel) become inflamed, causing nausea, vomiting, fever, and abdominal pain.
53167
a
CT abdomen
QuestionChoice
A flexible sigmoidoscopy is used to view the rectum, sigmoid and descending colon to aid with diagnosis of diverticular disease; diverticulae especially affect the recto-sigmoid colon so a flexible sigmoidoscopy is an adequate technique to diagnose most cases. However, this is not performed in the acute setting due to risk of perforation.
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Flexible sigmoidoscopy
QuestionChoice
Colonoscopy is usually performed after acute diverticulitis to fully investigate the bowel for any underlying disease, such as cancer leading to constipation. It is not useful in the acute setting, and may risk perforation.
53170
d
Colonoscopy
QuestionChoice
Blood cultures will be indicated in this febrile patient. However, it will not be the best next test to confirm the diagnosis; a CT scan will be required to do this.
53171
e
Blood cultures
Concept
Chapter
# Summary

Diverticular disease is a clinical condition characterized by the presence of diverticula, or outpouchings of the mucosa and submucosa, typically affecting the sigmoid colon. Key signs and symptoms include constipation, left lower quadrant abdominal pain, and potentially rectal bleeding. Key investigations include physical examination, abdominal imaging, and blood tests. In cases of inflammation of the diverticula, known as diverticulitis, the primary management strategy includes oral antibiotics, and in more severe cases, hospital admission and intravenous antibiotics. Surgical intervention may be required for complications such as perforation, abscess formation, and fistulas.


# Definition

**Diverticular disease** is a term used to describe conditions related to the presence of diverticula, which are small, bulging pouches that can form in the lining of the digestive system, most commonly in the lower part of the colon (sigmoid colon).

**Diverticulosis** refers to the simple presence of diverticula. In many cases, diverticulosis is asymptomatic, and individuals may not even be aware that they have these diverticula as they are typically discovered incidentally during tests for other conditions.

**Diverticulitis**, a subset of diverticular disease, occurs when these diverticula become inflamed or infected. This condition is typically characterized by severe abdominal pain, fever, and nausea. Diverticulitis often requires treatment, which can include antibiotics, pain relievers, and, in severe cases, surgery.

# Epidemiology

Diverticular disease is most common in individuals over the age of 50 and those who consume a Western (low fibre) diet.

# Aetiology

The primary risk factor for diverticular disease is age, with the condition being more prevalent in individuals over the age of 50. Other risk factors include consuming a low-fibre Western diet, obesity, lack of exercise, and certain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates.

# Signs and Symptoms

Diverticular disease typically presents with:

-   Constipation
-   Left lower quadrant abdominal pain
-   Possible rectal bleeding

Physical examination may be normal or may demonstrate tenderness in the left lower quadrant on digital rectal examination.

In cases of diverticulitis, the condition presents acutely with:

-   Left lower quadrant abdominal pain
-   Fever
-   Nausea/vomiting
-   Pyrexia and left lower quadrant tenderness/guarding on physical examination
-   Diffuse abdominal tenderness suggestive of perforation or generalised peritonitis.

# Differential Diagnosis

The differential diagnosis for diverticular disease includes:

-   Irritable bowel syndrome: Characterised by chronic abdominal pain, bloating, and alterations in bowel habits without an identifiable cause.
-   Colonic carcinoma: Presents with a change in bowel habits, rectal bleeding, abdominal pain, and unexplained weight loss.
-   Inflammatory bowel disease: Marked by abdominal pain, diarrhoea, bloody stools, weight loss, and fatigue.
-   Gynaecological disorders (in women): May present with abdominal or pelvic pain, menstrual irregularities, and various urinary symptoms.
-   Urological disorders: These may involve symptoms such as frequency, urgency, dysuria, and lower abdominal pain.

# Investigations

Diverticular disease can be confirmed through a variety of tests, such as:

-   Abdominal imaging (CT scan or ultrasound)
-   Blood tests demonstrating inflammation (leukocytosis)
-   Colonoscopy/endoscopy

# Management

Management of diverticular disease depends on the severity and symptoms presented:

-   Asymptomatic diverticulosis: No treatment is required if diverticula are seen incidentally on imaging or endoscopy.
-   Symptomatic diverticular disease: Patients should be advised to increase dietary fibre intake and hydration. If there is evidence of diverticulitis (leukocytosis, fever), patients are initially managed with oral antibiotics (e.g. 7 days co-amoxiclav). Analgesia may also be required, prescribed in a step-wise fashion, starting with oral paracetamol. A low residue diet is also advised.
-   Management of diverticulitis: Patients unresponsive to antibiotics, or presenting with an abscess, perforation, stricture, or obstruction may require surgical intervention. A localised abscess may be drained under CT/ultrasound guidance, with surgery considered if this fails.
-   Recurrent severe episodes of diverticulitis may necessitate consideration for elective colectomy.
-   For acute rectal bleeding: Haemodynamic stabilisation of the patient should be followed by endoscopic haemostasis. Surgery is an option if bleeding continues despite endoscopy.

# Complications

Diverticular disease can lead to both short and long-term complications:

Short-term complications include:

-   Abscess formation: Initially managed with bowel rest, broad-spectrum antibiotics ± CT-guided percutaneous drainage. Surgical management is considered if medical management fails.
-   Perforation: A surgical emergency suspected in cases of generalised peritonitis. Free air on the abdominal x-ray and high clinical suspicion necessitate urgent exploratory laparotomy.

Long-term complications include:

-   Fistula formation: Most commonly colovesical fistulas, presenting with pneumaturia, faecaluria, and recurrent UTIs. Diagnosed with cystoscopy or cystography and require surgical repair. Colovaginal, coloenteric, colouterine, and colourethral fistulas may also occur.
-   Fibrosis: Secondary to inflammation, resulting in strictures and large bowel obstruction.
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General Surgery
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Quesmed Tutorial: General and Vascular Surgery SBAs 
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A 62-year-old woman presents to A&E with a 2-day history of abdominal pain and nausea. She has also experienced some rectal bleeding but she thinks this is due to straining. She last opened her bowels earlier this morning. Her diet has been poor since her husband recently passed away. On examination, there is tenderness in the left lower quadrant and her abdomen is non-distended. Her vital signs are: HR 102 bpm, RR 15 breaths per minute, BP 139/97mmHg, temperature of 39.2.

Which of the following is the next best investigation to confirm the most likely diagnosis?
a