Complications
Formed when diverticular abscess ruptures into adjacent organs such as the urinary bladder in men, and vagina in women.[108]
Colovesical fistulae usually present with pneumaturia, faecaluria, and recurrent urinary tract infections.[109]
Passage of faeces or flatus from the vagina is diagnostic of colovaginal fistula.
Less common fistulas include coloenteric, colouterine, and colourethral.
Diagnostic modalities include cystoscopy, cystography, methylene blue studies, and contrast radiographs.
Surgical resection is the treatment of choice.[108][109]
If perforation has occurred, antibiotics should be used to prevent generalised peritonitis and septicaemia.
Although there is no established causal association between diverticulosis and colorectal neoplasia, there is an increased risk of colonic malignancy, in particular in complicated diverticulosis.[111][112]
High index of suspicion and a low threshold for screening colonoscopy is recommended for an early detection and possible curative treatment of colorectal neoplasia in these patients.[111][112][113]
Palpate for an abdominal mass on examination or perirectal fullness on digital rectal examination.[39]
Diagnostic laparoscopy/exploratory laparotomy should be considered early if primary diagnosis is unclear in a patient with peritonitis.
Most small pericolic abscesses respond to bowel rest and broad-spectrum antibiotics. Computed tomography-guided percutaneous drainage of abscesses can accelerate healing and eliminate the need for surgery.[6]
Surgery is required when medical treatment and percutaneous drainage does not result in clinical improvement. Surgery should also be considered in cases of multiloculated or inaccessible abscesses. An abscess at a remote site in the abdomen may still be a complication of diverticulitis even in the absence of significant left lower abdominal symptoms.
Check for rigidity and guarding on examination.[39]
Microperforation is usually self-contained and conservative treatment including antibiotics, intravenous fluids, and bowel rest result in complete healing. However, free air perforation is a surgical emergency, as untreated it may result in generalised peritonitis associated with significant morbidity and mortality. When expertise is available, laparoscopy and laparoscopic peritoneal lavage may be an alternative option.[85][86][87][88]
Inflammation and fibrosis may result in strictures, which in turn can cause partial or complete obstruction. Bowel obstruction may also result from pressure of inflamed bowel loop or small intestinal loop(s) being entangled in the inflammatory process. Ileus and pseudo-obstruction is also seen.
In cases of stricture, differentiation should be made from an obstructing neoplasm; colonoscopic biopsy will be required in this scenario.
Balloon dilation and stent placement may be considered as treatment.[110] Failure of dilation or inability to rule out malignancy mandates surgical resection.
Bowel rest, nasogastric suction, and intravenous antibiotics can result in resolution of partial obstruction. If the condition does not improve by conservative management or bowel ischaemia is evident, surgical intervention is indicated.
Pseudo-obstruction should be managed conservatively by correcting predisposing causes such as sepsis, electrolyte disorders, administering IV fluids, and nasogastric suction.
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