1.11.3 Diverticulitis and Diverticulosis

Question 1

What is diverticulosis?

What area most likely to develop?

Other Areas?

What are risk factors?

Answer 1

• Definition
  
  • Sac-like protrusions in colon wall
  • Herniation of mucosa and submucosa through muscular layers
  • NON-INFLAMED
  • Typically Asx
• Most common
  
  • Sigmoid colon (95%)
  • May have diverticuli in multiple large bowel areas, including ascending colon
    
    • Ascending colon diverticula can bleed, leading to hematochezia
• Other Locations
  
  • Duodenal
  • Jejunoileal
  • Meckel’s: most common congenital GI tract abnormality
    
    • 2-3% incidence, usually in children (intussusception, bleeding)
    • Rarely dx in adults
    • Presentation mimics appendicitis (RLQ pain)
    • Painless melena in adults
• Risk factors
  
  • Western diet (low fiber, high fat, red meat)
  • Obesity, inactivity
  • NSAID use, Opioid use
  • Decreased colonic motility, constipation, obstipation
  • Smokers - increased risk of diverticular perforation and abscess development
  • Marfan’s Syndrome: 20% incidence
  • Age
    
    • By age 60, 40-60% of people will develop diverticulosis

Question 2

Describe symptomatic, uncomplicated, and complicated presentations of diverticulosis

Answer 2

• Symptomatic
  
  • Persistent abd pain
• Uncomplicated
  
  • No diverticulitis or colitis
• Complicated
  
  • Presence of diverticulitis and/or colitis

Question 3

Describe tx for diverticulosis

Answer 3

• Focused on risk factor modification/prevention
  
  • High fiber diet
  • Physical activity
  • Use of statins
  • Increased Vit D

Question 4

Describe the relation btwn diverticulosis and diverticulitis

Describe presentation of diverticulitis

What will you find on physical exam?

Answer 4

• Increased pressure within diverticular sacs in diverticulosis patient can lead to perforation
  
  • Perf leads to inflammation and focal necrosis of involved areas
• Presentation
  
  • Fever, abd pain (LLQ, RLQ, or suprapubic)
  • N/v, consti/obstipation, bloating, flatulence
• Exam
  
  • Localized abd tenderness
  • Abd distention
  • Tympany on percussion
  • Absent bowel sounds
  • Mass
    
    • Abscess = abd mass
    • Rectal mass felt in distal sigmoid rectal exam
  • Pneumaturia/fecaluria
    
    • If diverticula fistulize into bladder (colovesicular)
  • Colovaginal fistula
    
    • If diverticular fistulize into vagina

Question 5

What dx imaging will help diagnose diverticulitis? What will findings be?

What lab work? What findings on labs?

Answer 5

• Imaging:
  
  • CT Abd/Pelvis with Colonic Contrast
    
    • Preferred study
    • Bowel wall thickening, pericolic fat stranding (soft tissue inflammation), phlegmon, abcess
  • Acute abd series
    
    • Free air on upright chest/decubitus views
      
      • Also rules in/out ileus and obstruction
  • Barium enema
    
    • Avoid in acute diverticulitis
• Labs
  
  • CBC: leukocytosis with left shift
  • BMP: electrolyte derangements (dehydration?)
  • LFTs, amylase, lipase: exclude other causes of acute abdomen
  • Lactic acid: septic? perfusion? fluid resus?
  • Coags, type and screen: surgery may be pending

Question 6

Describe the HInchey Classification of Acute Diverticulitis

What is your go-to treatment for mild, outpatient cases of diverticulitis?

Answer 6

• IA: Phlegmon
• IB: Diverticulitis with pericolic or mesenteric abscess
• II: Diverticulitis with walled-off pelvic abscess
• III: Diverticulitis with generalized purulent peritonitis
• IV: Diverticulitis with generalized fecal peritonitis

Treatment

• CLD x2-3d, then advance as tolerated to a low-fiber diet
• Analgesia: APAP
• Antispasmodics: dicyclomine
• Abx

Question 7

What are commonly encountered bacteria in diverticulitis?

What abx will you employ for mild, outpatient therapy?

Answer 7

• Common diverticulitis bacteria
  
  • Gram Neg and Anaerobes
    
    • Enterobacteriaceae
      
      • E. coli, Klebsiella, etc
    • Bacteroides
    • Enterococcus
      
      • E. faecalis (most common), E. faecium
• Outpatient Abx Therapy for Diverticulitis
  
  • Ampicillin/sulbactam (augmentin)
  • Ciprofloxacin/levoflocacin AND flagyl
  • TMP-SMX and flagyl
  • Moxifloxacin for mild cases/drained perirectal abscesses

Question 8

When will you consider admitting your diverticulitis patient?

What is your inpatient management for:

Mild to Moderate

Severe/Life Threatening

Answer 8

• Admit your patient if
  
  • Unable to maintain PO hydration
    
    • Vomiting
  • Peritoneal signs
  • Evidence of severe infection
  • Pain only relieved by IV narcotics
  • Fails 2-3d outpatient therapy
    
    • Worsening pain/fever, increasing leukocytosis
• Inpatient Management
  
  • Mild to Moderate
    
    • Surgical consult (may need percutaneous drainage versus surgery)
    • Isotonic fluid bolus per Surviving Sepsis Guidelines (if septic)
    • Abx:
      
      • Pip/Tazo (Zosyn)
        
        • Gram Neg, Anaerobes
      • Ertapenem
        
        • Gram Neg, Anaerobes
      • Moxifloxacin
      • Caution: Bacteroides species becoming resistant
  • Severe
    
    • Surgical consult for drainage, debridement, and/or repair
    • ABX
      
      • Meropenem
      • Imipenem-cilastin

Question 9

Describe the potential complications from diverticulitis

Answer 9

• Abscess formation
  
  • 30% of cases
• Perforation
  
  • Pneumoperitoneum seen on imaging
  • Peritonitis/sepsis can occur
• Fistula
  
  • Bladder (colovesical)
  • Vaginal (colovaginal)
  • Bowel (coloenteric/colocolonic)
  • Skin (colocutaneous)
• SBO from adhesions
  
  • From inflammation
  • From surgical intervention
• Pylephlebitis
  
  • Ascending septic thrombophlebitis
  • Thrombus causes occlusion of the portal vein or its branches
  • Quickly leads to bowel ischemia, perf, and sepsis