ANSWER 36
This woman has diverticulitis. Colonic diverticula are small outpouchings which are most
commonly found in the left colon. They are very common in the elderly Western popula-
tion probably due to a deficiency in dietary fibre. Symptomatic diverticular disease has
many of the features of irritable bowel syndrome. Inflammation in a diverticulum is
termed diverticulitis. In severe cases, perforation, paracolic abscess formation or septi-
caemia may develop. Other potential complications include bowel obstruction. formation
of a fistula into rectum or vagina, and haemorrhage.
The barium enema from 4 years ago shows evidence of diverticular disease with outpouch-
ings of the mucosa in the sigmoid colon. This would be consistent with the long-standing
history of abdominal pain of colonic type and tendency to constipation. The recent problems
with increased pain, tenderness, fever, raised white cell count and CRP and a mass in the left
iliac fossa would be compatible with an acute exacerbation of her diverticular disease. In her
case there is no evidence of peritonitis which would signal a possible perforation of one of
the diverticula.
The differential diagnosis, with the suggestion of a mass and change in bowel habit, would
be carcinoma of the colon and Crohn’s disease. In the absence of evidence of perforation
with leak of bowel contents into the peritoneum (no peritonitis) or obstruction (normal
bowel sounds, no general distension), treatment should be based on the presumptive diag-
nosis of diverticulitis. A colonoscopy should be performed at a later date to exclude the
possibility of a colonic neoplasm.
A CT scan of the abdomen will delineate the mass and suggest whether there is evidence
of local abscess formation. Treatment should include broad-spectrum antibiotics, intra-
venous fluids and rest. Further investigations are indicated, including electrolytes, urea
and creatinine, glucose, liver function tests and blood cultures. Repeated severe episodes,
bleeding or obstruction may necessitate surgery.
- Diverticular disease is a common finding in the elderly Western population and may be
asymptomatic or cause irritable bowel syndrome-type symptoms. - Diverticular disease is a common condition; its presence can distract the unwary doctor
from pursuing a co-incident condition. - Diverticulitis needs to be treated with antibiotics to reduce the chance of complications
such as perforation or fistula formation occurring.