Ischaemic colitis and diverticulitis Flashcards Preview

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Flashcards in Ischaemic colitis and diverticulitis Deck (25)
1

Outline the pathology of ischaemic colitis

Compromised perfusion to the marginal branches of the middle colic (SMA) and left colic (IMA) that supply the transverse and descending colon.

2

Which area of the colon is particularly susceptible to ischaemic colitis?

Splenic flexure

3

Name 3 predisposing factors for ischaemic colitis

Thrombosis of IMA
AAA repair commonly ligates IMA
Emboli
Decreased CO or arrhythmias
Shock
Trauma
Strangulated hernia or volvulus
Drugs: OCP, cocaine, antihypertensives, psychotropic
Abdominal surgery
Vasculitis
Coagulation disorders

4

Describe the presentation of ischaemic colitis

Sudden onset of abdominal pain, commonly in LIF
-typically occurs after eating
-pain out of proportion to clinical findings
Bright red PR bleeding
NaV
Diarrhoea

5

How should ischaemic colitis be investigated?

Urgent CT to exclude perforation
AXR would show thumb printing
Flexible sigmoidoscopy
Biopsy ➔ epithelial cell apoptosis and lamina propriety fibrosis

Later: Colonoscopy to exclude strictures and confirm mucosal healing

6

How is ischaemic colitis managed?

Many cases are resolved by correcting hypoperfusion
Symptomatic treatment
Surgery if fulminant ischaemic colitis + perforation/gangrene

7

Define diverticulum

Herniation of mucosa through thickened colonic muscle

8

Where are diverticula most commonly seen?

Sigmoid (85%) and descending colon

9

What lifestyle factor is diverticulum formation associated with?

Low-fibre diet - seen most in USA, Europe, and Australia

10

Name and describe the 3 conditions associated with diverticula

Diverticulosis (95%): Presence of asymptomatic diverticula
Diverticular disease: Symptomatic diverticula
Diverticulitis: Diverticular inflammation

11

What percentage of people aged 50+ have diverticula?

50%

12

Name 3 risk factors for diverticular disease

Aged 50+
Low fibre diet
Obesity

Complicated diverticular disease is commoner in patients who smoke, use NSAIDs, obese, low-fibre diets.

13

How does diverticulosis present?

Frequently an incidental finding on colonoscopy or barium enema.

14

How does diverticular disease present?

Large painless rectal bleed
Nonspecific abdominal complaints, usually left-sided:
-Intermittent lower abdominal/LIF pain
-Erratic bowel habit

Severe disease ➔ severe pain and constipation

Pain exacerbated by eating, diminished with defecation or flatus

NB. Isolated diverticular bleeds in absence of infection tend to spontaneously resolve ➔ active observation

15

How does diverticulitis present?

Severe lower abdominal pain
Fever
Malaise
Change in bowel habit
Rectal bleeding (occasional)

16

Name 4 complications of diverticulitis

Rectal bleeding (5-10%)
Abscess
Peritonitis
Fistula
Obstruction/stricture
Perforation

N.B. 25% of acute diverticulitis is 'complicated'

17

How should diverticular disease be investigated?

FBC ➔ inflammation in acute episodes
VBG ➔ lactate rule out mesenteric ischaemia
Colonoscopy: contraindicated in acute diverticulitis
Barium enema if uncomplicated
Erect CXR ➔ pneumoperitonium
AXR ➔ bowel obstruction, abscess
CT ➔ complicated diverticular disease

18

What is the management of diverticulosis?

Healthy high-fibre diet
Fluid intake

19

Outline the medical management of diverticular disease

Healthy high-fibre diet and fluids
Weight loss and smoking cessation

Laxatives
Analgesia

20

Outline the medical management of diverticulitis

Broad spectrum oral ABX
Analgesia
Clear liquids only ➔ gradual reintroduction of solid food
Check WCC and CRP for infection

21

What are the surgical indications for diverticulitis?

Acute complicated diverticulitis
Not improving with medical treatment

22

Outline the surgical treatment of diverticulitis

Sigmoid resection +/- colostomy
Percutaneous drainage of abscesses
Peritoneal lavage

23

What medication increases the risk of bleeding in diverticular disease

NSAIDs e.g. Diclofenac for arthritis pain

24

How should acute diverticulitis be followed-up?

Colonoscopy 2-6wk after resolution: confirms diagnosis, looks at complications such as strictures, and rules out other pathology such as colitis or carcinoma.

Advice to maintain high-fibre diet

25

Outline the Hinchey classification

Used to describe perforated acute diverticulitis
I. Pericolic or mesenteric abscess
II. Walled-off pelvic abscess
III. Generalised purulent peritonitis (5% mortality)
IV. Generalised faecal peritonitis (35% mortality)

May be used as a guide to the suitability for primary anastomosis following resection