Diverticular disease

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Diverticular disease
Diagnosis in short

Diverticulum. H&E stain.

LM mucosa/submucosa invaginate into the musuclaris propria
Gross outpouching - best seen after sectioning
Grossing notes partial colectomy for diverticular disease
Site colon - classically sigmoid, other sites

Associated Dx diverticulitis, peritonitis, diverticular disease-associated colitis
Symptoms usu. asymptomatic, diverticulitis presents with abdominal pain - classically left lower quadrant
Prevalence common - especially elderly
Radiology colonic outpouchings (typically sigmoid colon) +/-pericolic stranding
Clin. DDx colorectal carcinoma, epiploic appendagitis
Treatment usually conservative, surgical resection (recurrent or perforating diverticulitis)

Diverticular disease, also diverticulosis, is a common disease of the colon. Inflammation of diverticula is known as diverticulitis.

General

  • Very common.
  • Typically seen in elderly patients - 50s and 60s.

Presentations:

  • Incidental finding on imaging.
  • Abdominal pain.
    • Classically left lower quadrant.
    • +/-Peritoneal signs.
  • Blood per rectum.
  • Large bowel obstruction.

Complications:

  • Diverticulitis - seen in ~25% of individuals with divertiulosis.[1]
  • Peformation - peritonitis.
  • Diverticular-associated colitis - see below.
  • Bowel obstruction - not common, may mimic malignancy.[2]

Diverticular disease-associated colitis

Features:[3]

  • Rare.
  • Definitions vary somewhat - one is: IBD-like inflammation restricted to areas with diverticular disease.
  • Considerable overlap with IBD histologically - no definite histologic findings.
  • Rectal biopsy may be used to differentiate from ulcerative colitis.

Gross

  • Corrugated - like cardboard.
  • Wall thickening (reactive).[4]
  • Usually sigmoid colon.
    • May be elsewhere, e.g. appendix.[5]

Endoscopic image

Microscopic

Features:

  • Mucosa/submucosa invagination into the musuclaris propria (MP).
    • At the site the blood vessels supplying the mucosa and submucosa penetrate the MP.[6]

Notes:

DDx:

Images

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Sternberg's Diagnostic Surgical Pathology suggests using the term diverticular disease instead of trying to distinguish between diverticulosis and diverticulitis, as diverticulitis clinically may be seen without objective evidence of inflammation.[9]

Sigmoid Colon, Sigmoidectomy:
- Diverticular disease with surrounding fibrosis and small focus of 
  active mucosal inflammation.
- Four benign lymph nodes.
- NEGATIVE for malignancy.

Block letters

SIGMOID COLON, SIGMOIDECTOMY:
- DIVERTICULAR DISEASE WITHOUT EVIDENCE OF ACTIVE DIVERTICULITIS.
- NEGATIVE FOR MALIGNANCY.
 SIGMOID COLON WITH EEA DONUTS, SIGMOIDECTOMY:
- DIVERTICULAR DISEASE WITHOUT EVIDENCE OF ACTIVE DIVERTICULITIS.
- ONE BENIGN SMALL LYMPH NODE.
- NEGATIVE FOR MALIGNANCY.

Perforated

RECTO-SIGMOID, LARGE BOWEL RESECTION:
- PERFORATED DIVERTICULITIS WITH SEROSITIS AND ABSCESS FORMATION.
- SUBMUCOSAL FIBROSIS.
- ONE LYMPH NODE NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 1 ).
- NEGATIVE FOR MALIGNANCY.
SIGMOID COLON, RESECTION:
- COLONIC PERFORATION ASSOCIATED WITH FAT NECROSIS, SEROSITIS AND MICROABSCESS
  FORMATION, IN THE SETTING OF DIVERTICULAR DISEASE.
- ONE LYMPH NODE NEGATIVE FOR MALIGNANCY ( 0 POSITIVE / 1 ).
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

See also

References

  1. Agarwal, AK.; Karanjawala, BE.; Maykel, JA.; Johnson, EK.; Steele, SR. (Sep 2014). "Routine colonic endoscopic evaluation following resolution of acute diverticulitis: is it necessary?". World J Gastroenterol 20 (35): 12509-16. doi:10.3748/wjg.v20.i35.12509. PMID 25253951.
  2. Pereira, JM.; Sirlin, CB.; Pinto, PS.; Jeffrey, RB.; Stella, DL.; Casola, G.. "Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain.". Radiographics 24 (3): 703-15. doi:10.1148/rg.243035084. PMID 15143223.
  3. Mulhall, AM.; Mahid, SS.; Petras, RE.; Galandiuk, S. (Jun 2009). "Diverticular disease associated with inflammatory bowel disease-like colitis: a systematic review.". Dis Colon Rectum 52 (6): 1072-9. doi:10.1007/DCR.0b013e31819ef79a. PMID 19581849.
  4. Nicholson, BD.; Hyland, R.; Rembacken, BJ.; Denyer, M.; Hull, MA.; Tolan, DJ. (Aug 2011). "Colonoscopy for colonic wall thickening at computed tomography: a worthwhile pursuit?". Surg Endosc 25 (8): 2586-91. doi:10.1007/s00464-011-1591-7. PMID 21359889.
  5. Sohn, TJ.; Chang, YS.; Kang, JH.; Kim, DH.; Lee, TS.; Han, JK.; Kim, SH.; Hong, YO. (Jan 2013). "Clinical characteristics of acute appendiceal diverticulitis.". J Korean Surg Soc 84 (1): 33-7. doi:10.4174/jkss.2013.84.1.33. PMID 23323233.
  6. West, AB.. "The pathology of diverticulitis.". J Clin Gastroenterol 42 (10): 1137-8. doi:10.1097/MCG.0b013e3181862a9f. PMID 18936652.
  7. Goldstein, NS.; Ahmad, E. (Apr 1997). "Histology of the mucosa in sigmoid colon specimens with diverticular disease: observations for the interpretation of sigmoid colonoscopic biopsy specimens.". Am J Clin Pathol 107 (4): 438-44. PMID 9124212.
  8. URL: http://histology-group28.wikispaces.com/DigestiveSystemProject. Accessed on: 23 August 2011.
  9. Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1346. ISBN 978-0781779425.