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Case 8.1 – Diverticular Disease

Category: Surgery | Discipline: Surgery - GIT | Setting: Emergency Department

Case

Ellen Cassidy, aged 68 years, presents with acute abdominal pain localised to the left iliac fossae. She has a swinging fever with peak temperatures of 38.9°C and suffered diarrhoea two days ago but since then has been constipated. She had an episode 1 year ago that was similar but milder as symptoms resolved in a day.

Questions

1. What further history and examination would you undertake?

History (SOCRATES)

  • Site, radiation, character of the abdominal pain, severity
  • Time of onset (both episodes)
  • Time-intensity relationships
  • Exacerbated by; relieved by
  • Associated features - appetite, weight change, night sweats, change bowel habits (diarrhoea/constipation; rectal bleeding)
  • Dietary features (is it related to certain foods?)
  • Routine GIT history (incl. systems review)

Examination

  • Formal GIT system examination
    • Fever
    • Characteristic left lower quadrant tenderness
    • Palpable mass?
    • Presence of complications (e.g. perforation/peritonitis; fistula)
  • Including digital rectal examination
  • Inguinal/femoral, supraclavicular lymph nodes
2. What is the difference between diverticulosis and diverticulitis?

Diverticulosis (diverticular disease without complication)

  • Diverticulae in the colon - mucosal herniations through the muscular wall
  • Asymptomatic but may become complicated, then symptoms develop

Diverticulitis

  • Inflammation/infection of one or more diverticulae
  • Including extension into adjacent tissue
  • Initiated by obstruction of the neck of the diverticulum by a faecolith
  • Obstruction leads to edema in the colon wall or may be complicated by micro or macro perforation
  • Fever and leukocytosis are characteristic
3. List the indications for surgery for diverticular disease?

Elective Indications

  • Recurrent attacks/increasing severity
  • Younger patient
  • Chronic pain
  • Fistula formation (colo-vaginal; colo-vesical; colo-cutaneous)
  • Conservative measures not controlling symptoms (high fibre diet, supplements)
  • Symptoms of recurrent pain and functional changes in bowel habits become unacceptable for the patient
  • Perforation(s) not confined to pericolic tissues and controlled by antibiotics

Emergency Indications

  • Bleeding
  • Perforation (macroscopic with generalised peritonitis, or failed conservative management)
  • Obstruction
4. Summarise the blood supply of the colon and explain the significance of anastomotic zones for surgeons.

Blood Supply of the Colon

Region Blood Supply
Caecum, ascending colon, most of transverse colon Superior mesenteric artery (via ileocolic, middle colic arteries – only minority have right colic artery as well)
Splenic flexure, descending colon, sigmoid colon Inferior mesenteric artery (via ascending colic and sigmoid arteries from IMA)
Superior rectum Final branch of the inferior mesenteric artery (superior rectal arteries)
Middle and inferior rectum Branches of the internal pudendal arteries (inferior rectal artery)

Significance of Anastomotic Zones for Surgeons - "Marginal Zones"

Certain parts of the colon (e.g. splenic flexure) are at the junction of two separate blood supply systems and may be relatively poorly perfused. For this reason, anastomoses in this region would carry a higher risk of ischaemic complications.

5. Summarise the principles of colonic motility and list three common organisms in the colon.

Principles of Colonic Motility

  • Multiple types of contraction patterns
  • Segmentation contractions and mass contractions – unique to the colon, characterized by contractions of large segments of the colon, resulting in mass movement of stool
  • Movement of residue through colon occurs at slow rate (18-48 hours) compared to small bowel (4 hours)
  • Colonic transit accelerated by: emotional states, diet, disease, infection, medications and bleeding

Three Common Organisms in the Colon

  • Bacteroides fragilis
  • Escherichia coli
  • Enterococci (Strep. faecalis)
6. A number of diagnostic investigations can be ordered to investigate the colon. Briefly summarise the following: rigid sigmoidoscopy, fiberoptic sigmoidoscopy, abdominal series x-ray, barium enema, colonoscopy, angiography.

Diagnostic Investigations for the Colon

Investigation Description and Uses
Abdominal X-ray Series
  • Supine and erect radiographs
  • Should be obtained on any patient presenting with significant abdominal pain
  • Helpful in detecting: pneumoperitoneum, small bowel obstruction, large bowel obstruction (volvulus, tumour), renal calculi
Barium Enema
  • After colon and rectum prepared, barium contrast medium introduced under mild pressure to fill the entire organ
  • DCBE (Double Contrast Barium Enema): Air insufflation, with some intraluminal barium remaining, allows sensitive detection of polyps and small lesions
  • Helpful in diagnosing: tumours, diverticulosis, volvulus, sites of obstruction
  • Less used as colonoscopy widely available and use of CT/oral contrast or CT colonography increases
Rigid Sigmoidoscopy Now largely replaced by flexible fibre-optic sigmoidoscopy
Flexible Sigmoidoscopy
  • Provides higher diagnostic yield and more comfortable for patient
  • Allows visualization of last 30-60cm of large bowel
  • Detects up to 60% of colorectal neoplasms
  • Has a role in screening for neoplasia and/or in centres where colonoscopy not widely practised
Fibre-optic Colonoscopy
  • Allows visualization of the entire colon and rectum, plus/minus last few cm of terminal ileum
  • Therapeutic options: polyp removal, colonic decompression, stricture dilatation, haemorrhage control, foreign body removal
  • Requires thorough bowel preparation and mild sedation
  • Primary diagnostic modality for: lower GIT bleeding of unknown aetiology, inflammatory bowel disease, stricture, equivocal imaging findings, lower abdominal pain, patients with personal or family history of colorectal polyps and cancer
Angiography
  • Useful in detecting the source of moderate or rapid colonic bleeding
  • Not helpful in slow or chronic blood loss
  • Requires radiologic expertise, as usually an emergency procedure

Other Investigations

  • Colonic Transit Studies - for investigation of motility disorders
  • Small Bowel Series/Enterography – for investigation of small bowel pathology
  • MRI – Inflammatory bowel disease, limited indications