QuestionSBA
QuestionChoice
This may rarely present with bowel perforation, but is not as common a cause for bowel perforation as diverticulosis. Advanced colon cancer may more likely present with bowel obstruction or PR bleeding
31985
c
Colon cancer
QuestionChoice
This may rarely present with bowel perforation, but is not as common a cause for bowel perforation as diverticulosis
31987
e
Appendicitis
QuestionChoice
This would cause perforation of the duodenum or stomach rather than bowel perforation
31984
b
Peptic ulcer disease
QuestionChoice
Diverticular disease is the most common underlying pathology found in cases of bowel perforation in elderly patients. Diverticulosis refers to the asymptomatic presence of diverticula in the large bowel
31983
a
Diverticular disease
QuestionChoice
It is unlikely that a man of this age would present with ulcerative colitis for the first time. It may also rarely cause bowel perforation but is not as a common a cause as diverticulosis
31986
d
Ulcerative colitis
QuestionComment
duodenum not bowel? 
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# 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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A 80 year old man presents to the accident and emergency department with sudden onset abdominal pain and feeling generally unwell for the last 2 hours. He has no significant past medical history.

An erect chest x-ray shows free air under the diaphragm, and a CT abdomen/pelvis confirms a bowel perforation.

What is the most likely underlying pathology in this patient?
a