Complications of diverticular disease

Diverticulitis has been likened to appendicitis, with a diver-ticulum becoming obstructed by inspissated stool in its neck. The inflammatory process varies in severity from inflammation alone to pericolic abscess to free perforation of the colon with faecal peritonitis. Most patients present with symptoms of pain and signs of tenderness or a mass accompanied by varying degrees of systemic inflammatory response. CT scanning is regarded as the diagnostic modality of choice. Endoscopy is generally avoided due to the increased risk of perforation.

Pericolic abscess may result from the perforation of a diverticulum; when identified an abscess should be drained percutaneously if possible. Diverticular disease may lead to fistulas into adjacent organs; the most common is colovesi-cal fistula. Colovaginal fistula may also occur and are more common if the patient has had a previous hysterectomy. Diverticular disease is the commonest cause of major lower gastrointestinal (GI) bleeding (see following section).

Treatment is based on confirming the diagnosis (exclusion of co-existing colonic carcinoma is sometimes difficult as the features of both conditions can appear to overlap on colonic imaging) and conservatism is generally advised for mild attacks. Treatment with antibiotics usually settles mild attacks and dietary advice is given to increase both fibre and fluid in the diet. Pericolic abscess should be treated by percutaneous drainage and patients with peritonitis or colonic fistulas are usually submitted to laparotomy and colonic resection. Whether to reconstruct intestinal continuity or leave the patient with a Hartmann's operation is dependant on the patient's general condition, the state of the bowel (presence of infection usually precludes anastomosis) and the skill, and experience of the surgeon.

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