2- Diverticular disease Flashcards
What are defined as sac-like protrusions of the colonic wall?
Diverticulum/ diverticula
What is defined as the presence of diverticula?
Diverticulosis
What is defined as inflammation of a diverticulum?
Diverticulitis
How does the prevalence of diverticulosis change with age?
Increases with age
What portion of the colon is primarily affected by diverticulosis?
Sigmoid
How does diverticulosis generally present clinically?
Asx, discovered incidentally, normal PE
(occasionally abd cramping, constipation, diarrhea, bloating)
What is the pathophysiology of diverticulosis?
- Develop at weak points in colon wall
- Increased intraluminal pressure predispose mucosa and submucosa to herniate
- Low fiber diet → constipation → intraluminal pressure → herniation
What are the complications of diverticulosis?
Diverticulitis, bleeding
For pts who present with diverticulosis that clinically manifests as diverticulitis, are the majority simple or complicated?
Simple (85%)
Are labs/ imaging typically required for diverticulosis?
No- most discovered incidentally on colonoscopy/ imaging
How is asx diverticulosis managed?
High fiber diet (20-35 g/ day), adequate hydration
What is NOT recommended for management of asx diverticulosis?
Avoidance of seeds/ nuts
What is the pathophysiology of acute diverticulitis? (4 steps)
Debris obstructs diverticulum neck/ increased luminal pressure results in erosion of diverticular wall → inflammation/ focal necrosis → perforation (micro or macro) → free air/ peritonitis
What is defined as intra-abdominal spread of bacteria/ fecal matter?
Peritonitis (emergency)
What defines acute diverticulitis as complicated? (4)
Abscess, fistula, obstruction, perforation
Pt presents with progressive, steady aching pain in the LLQ, fever/ chills, (+/- N/V, change in bowel habits, irritative urinary sxs, peritoneal signs, and tenderness on rectal exam). What are you concerned for?
Acute diverticulitis
What are the causes of irritative urinary sxs (if present) in acute diverticulitis?
Pneumaturia (air in urine) or fecaluria (fecal matter in urine) if colovesical fistula
If pt presents with sxs consistent with acute diverticulitis, what is important to review as part of their hx?
Prior hx of diverticulitis episodes
If concern for acute diverticulitis, what exam should be performed in women?
Pelvic
What lab diagnostics should be ordered if concern for acute diverticulitis?
If of childbearing age?
If diarrhea?
If occult blood?
CBC (leukocytosis), BMP/ CMP, UA/ urine culture
If of childbearing age → urine HCG
If diarrhea → stool studies
If occult blood → stool
What is the test of choice for diagnostic eval of acute diverticulitis?
CT scan of AP w/ contrast
(localized bowel wall thickening/ fat stranding, colonic diverticula)
Aside from CT of A/P with contrast (test of choice), what other imaging might be ordered for diagnostic eval of acute diverticulitis?
Abd/ chest x-ray, US
What diagnostic studies are contraindicated for eval of acute diverticulitis?
Flex sigmoidoscopy/ colonoscopy (risk of perf)
Barium enema (leakage through perf and exacerbation of peritonitis)
What is the management for uncomplicated acute diverticulitis?
Discharge home (+/- abx), clear liquid/ low residue diet, close f/u within 2 days
What is the management for complicated acute diverticulitis?
Admit, NPO, IV fluids, IV abx, consult GI, surgery
What is typically recommended for abx in the tx of acute uncomplicated diverticulitis?
G-/ anaerobic coverage x 7-10 days
- Metro + Cipro
- Metro + Bactrim
- Augmentin
- Modifloxacin (if tolerant to metro and beta-lactams)
What are guidelines regarding repeat imaging for acute uncomplicated diverticulitis?
Not necessary if clinical improvement
The following are indicative of what for acute diverticulitis?
- CT shows complicated diverticulitis
- Significant leukocytosis
- High fever ( > 102.5)
- Severe/ increasing abd pain
- Peritoneal signs
- Comorbidites/ IMC
- Inability to tolerate PO
- Noncompliance/ unreliability/ lack of support
- Eldely
Inpatient management
What are guidelines regarding repeat imaging for acute diverticulitis with inpatient management?
Repeat imaging necessary if failure to improve within 2-3 days of IV abx therapy
When treating acute diverticulitis with inpatient management, what is the protcol after IV abx therapy?
Transitioned to PO abx to complete a total of 10-14 day course
When is surgical referral for management of acute diverticulitis indicated? (3)
- Perf w/ peritonitis
- Deterioration/ failure to improve w/i 72 hrs of therapy
- Complicated
What is included as part of long-term management of acute diverticulitis?
High fiber diet once acute episode resolves
Colonoscopy performed 6-8 weeks after resolution to eval extent of disease/ exclude colon CA/ IBD
The decision to perform prophylactic colonic resection in patients with recurrent diverticulitis is based on what?
Individualized (if uncomplicated, may not be necessary)
What is a common cause of overt lower GI bleeding in adults and usually resolves spontaneously?
Diverticular bleeding
A penetrating artery draped over the dome of diverticulum leading to easy exposure to injury and susceptibility to bleeding is the pathophysiology for what?
Diverticular bleeding (R colon often source of bleed)
Pt presents with painless hematochezia, TTP on abd exam, blood on rectal exam, +/- bloating/ cramping/ fecal urgency/ abn vital signs. What are you concerned for?
Diverticular bleeding
What diagnostics should be ordered for initial eval of diverticular bleeding?
CBC, CMP, EGD/ NG lavage
(BUN/Cr not elevated if colonic diverticular bleeding)
Once initial resuscitation for diverticular bleeding is complete, what is the next step?
Locate source of bleeding with flex sig/ colonoscopy
What is included in the management of diverticular bleeding?
Usually self limited but if necessary:
Resuscitation/ hospitalization (maintain blood volume)
Treatment of bleeding site (endoscopic therapy, angiographic therapy, +/- surgery)
