DIVERTICULAR DISEASE

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Diverticular disease of the colon is where “pockets” occur at weaknesses
in the colon wall. These pockets are called diverticula. These pockets
typically occur in the last part of the colon before reaching the rectum (the
sigmoid colon). When one or more of these diverticula rupture it results in
inflammation or infection of the involved colon (diverticulitis).

CAUSE
Age and constipation are the leading causes of diverticular disease.
Constipation results in the colon needing to generate very high pressures to
squeeze the firm faeces along the colon. These high pressures result in
“blowouts” with pockets or pouches (called diverticula) in the wall of the
colon at weaknesses in the muscle wall where the blood vessels enter. When a
diverticulum ruptures (even if microscopic), it leads to inflammation and
infection of the involved colon (diverticulitis). If the diverticulum erodes
into an adjacent blood vessel it can result in bleeding into the colon.

SYMPTOMS
Frequently diverticular disease is not associated with symptoms. However
when there is inflammation or infection (diverticulitis), this may result in
abdominal pain and fevers. Per rectal bleeding can occur with diverticular
disease when the diverticula is wide and causes mucosal erosion into an
adjacent vessel. It is rare for diverticulitis and bleeding to occur together.

INVESTIGATION
Frequently diverticulosis is present without symptoms and the diagnosis
is picked up by chance on colonoscopy or on gastrograffin enema.

If the presentation is abdominal pain and fever consistent with
diverticulitis, then a CT scan will confirm the diagnosis showing a swollen
inflamed colon with associated diverticulosis. If the presentation is rectal
bleeding a CT angiogram may be needed to determine that it is
diverticular bleeding. This will also tell the site of bleeding.

Diverticular disease of the colon

 

COURSE
Most cases of diverticular disease will never become symptomatic, with
attacks of diverticulitis or per rectal bleeding very uncommon. Diverticulitis
usually settles with antibiotics. Repeated attacks of diverticulitis are
worrying and you should consult your colorectal surgeon to discuss the role of
prophylactic surgery.

Diverticular bleeding is also uncommon, but when it occurs can result in
significant per rectal bleeding, and warrants admission to hospital. Sometimes
the bleeding must be stopped by injecting an agent (thrombin) via a groin
artery (angiography) into the bleeding vessel (embolisation). Even more rarely
emergency surgery is required to stop diverticular bleeding.

PREVENTION
A healthy diet high in fibre and a good intake of fluid to prevent
dehydration and constipation is the best way to avoid diverticular disease.
Constipation is sometimes resistant to dietry methods alone. Laxatives that
prevent constipation include those containing psyllium husks (Metamucil®,
Fibogel®), lactulose (Duphulac®), and sterculia (Normacol®). Attacks of
diverticulitis are occasionally triggered by certain foods (e.g. nuts) however
the evidence for this is weak.

MEDICAL MANAGEMENT
Diverticulitis with inflammation or infection of the affected colon
usually settles with intravenous antibiotics, followed by an extended course of
oral antibiotics following discharge from hospital. Diverticular bleeding is an
indication for admission to hospital, but in most cases stops without treatment
and only rarely requires embolisation or surgery.

SURGICAL MANAGEMENT
Recurrent attacks of diverticulitis warrant discussion with your
colorectal surgeon about the benefits of prophylactic surgery (sigmoid
colectomy). This is usually performed as a laparoscopic (key hole) procedure
without the need for a temporary stoma bag.


 Laparoscopic Sigmoid Diverticular Colectomy

WHAT TO EXPECT PRE AND POST OPERATIVELY FOR SIGMOID DIVERTICULAR
COLECTOMY

You will need to have only clear fluids the day before
your surgery. Clear liquids are those that one can see through. When a clear
liquid is in a container such as a bowl or glass, the container is visible
through the substance. You will also require bowel prep to clean your colon.
Take a pico-sulfate sachet (also called Picoprep® or Picolax®) at 2pm, 4pm and 6pm the day before
your procedure. You need to fast from midnight the night before if your surgery is scheduled for the morning,
or from 6am if scheduled for the afternoon. Immediately after your procedure
you will be commenced on free fluids (semi thickened fluids such as custard,
yoghurt, thin porridge). You will be given a combination of opioid and
paracetamol analgesia to allow you to mobilise from day one. You will be
discharged from hospital once you have opened your bowels. A typical admission
is anywhere from 3 to 7 days.

 

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