DIVERTICULAR COLONIC DISEASE Part 2 Flashcards
What is the role of abdominal radiography (plain films) in the initial evaluation of diverticulitis?
Abdominal radiography (plain films) is a good initial step.
It can show signs of ileus, occlusion, mass effect, perforation.
What are the advantages and limitations of ultrasonography (US) in evaluating acute diverticulitis?
Advantages: Non-invasive and can be a safe examination.
Limitations: 20% of examinations are sub-optimal due to aerocolia and it is very operator-dependent.
When is computer tomography (CT) particularly useful in cases of diverticulitis?
CT is very useful in complications.
CT evaluation for other diseases should be taken into account in all cases of diverticulitis associated with a palpable mass.
CT evaluation is warranted when the patient’s condition is severely affected.
When is colon enema (irrigography) with water-soluble contrast considered safe and useful in cases of diverticulitis?
In cases of moderate severity, when the diagnosis is in doubt, the examination is safe and useful.
What is the contraindication for colonoscopy in diverticulitis?
Acute diverticulitis is a contraindication for endoscopy; perforation should be excluded first.
When does colonoscopy apply in the context of diverticulitis?
It applies only if the diagnosis could not be established by other methods.
When the symptoms of the ringing are represented by anemia, rectorrhagia.
For the exclusion of other diseases: ischemic colitis, ulcerative colitis, Crohn’s disease, CCR (colorectal cancer).
CT Scan
➢ Marked thickening of distal end
of the descending colon
➢ Inflammatory changes (straight
arrow)
➢ Extraluminal gas (curved arrow)
How does a peridiverticular abscess develop?
The result of the spontaneous evolution of a perforation with suprainfection.
What are the possible outcomes of suppuration in peridiverticular abscess?
Due to the antibiotic treatment administered in the constitution phase, the suppuration can be reabsorbed or remains circumscribed.
Where can a peridiverticular abscess open?
The abscess can open in a cavitary organ in the vicinity, in the skin, or in the peritoneal cavity.
What are possible distant complications of peridiverticular abscess?
Pylephlebitis
Liver abscess
How is peridiverticular abscess diagnosed?
Diagnosis – CT and/or US
What are the two types of secondary peritonitis that can occur in diverticulitis?
Purulent / stercoral
What is the clinical picture of secondary peritonitis in diverticulitis?
Brutal pain in the left iliac fossa
Signs of shock
High fever
What are the abdominal findings on physical examination in secondary peritonitis?
Localized / generalized abdominal contracture
What are the auscultation findings in secondary peritonitis?
Decreased bowel sounds
What are the signs of pneumoperitoneum in secondary peritonitis?
Clinical signs of pneumoperitoneum with disappearance of liver dullness
What is a fistula?
A fistula is an abnormal connection of tissue between two organs or between an organ and the skin.
How do fistulas form in the context of infection?
When damaged tissues come into contact with each other during infection, they sometimes stick together; if they heal that way, a fistula may form.
How do fistulas develop in diverticulitis?
When diverticulitis-related infection spreads outside the colon, the colon’s tissue may stick to nearby tissues.
What organs are commonly involved in fistulas related to diverticulitis?
The organs usually involved are the bladder, small intestine, and the skin.
What is the most common type of fistula in diverticular disease?
The most common type of fistula occurs between the bladder and the colon.
Who is more often affected by colovesical fistulas?
This type of fistula affects men more often than women.
It can result in a severe, long-lasting infection of the urinary tract
How is a colovesical fistula treated?
The problem can be corrected with surgery to remove the fistula and the affected part of the colon.
What are the clinical signs suggesting a fistula in diverticular disease?
Passage of feces and gases (e.g., colo-vaginal fistula - leakage of feces through the vagina; colo-bladder fistula - pneumaturia, fecaluria).
What are the categories of fistulas in diverticular disease?
Internal fistulas.
External fistulas.
Give examples of internal fistulas in diverticular disease.
Colo-enteric or colo-colonic fistulas.
Give examples of external fistulas in diverticular disease.
Indirect through the cavitary visceral organs (vagina, uterus, bladder).
Direct - colo-cutaneous purulent/stercoral fistulas.
How are fistulas diagnosed?
Diagnostic - CT or Rx (e.g., air in the bladder).
How is bleeding explained anatomically in diverticular disease?
Bleeding is explained anatomically by the proximity between the diverticular area and the right vessels of the colon, with secondary erosion and rupture.
As the diverticulum increases, the vessel is separated only by a thin layer of muscle and can be susceptible to various aggressions.
What type of digestive hemorrhage can diverticula cause?
Cause of lower digestive hemorrhage.
What is the primary clinical manifestation of diverticular hemorrhage?
Rectorrhagia (rectal bleeding).
What are the characteristics of the rectal bleeding in diverticular hemorrhage?
Sudden onset.
Frequently abundant (massive bleeding), may require occasional blood transfusion.
What other symptoms may accompany rectal bleeding in diverticular hemorrhage?
May be present abdominal cramps, tenesmus.
What is necessary in the remaining cases of diverticular hemorrhage?
In the rest of the cases being necessary surgical intervention to perform hemostasis.
What diagnostic explorations are used in diverticular hemorrhage?
Angiography and radioisotopes – scintigraphy with marked erythrocytes with Tc.
Colonoscopy.
What are the main principles of treatment for diverticular disease?
Induction of remission.
Prevention of recurrences and complications.
What are the therapeutic methods used in the treatment of diverticular disease?
Diet.
Drug treatment.
Endoscopic treatment.
Surgical treatment.
What is the treatment for asymptomatic diverticulosis?
Dietary regime supplemented with vegetable fiber.
Bran from cereals – 3-5g/day with an increase to 15-20g/day.
What is the dietary recommendation for uncomplicated symptomatic diverticulosis?
Diet enriched with vegetable fibers.
How are patients with mild symptoms of uncomplicated symptomatic diverticulosis
Those with mild symptoms, without signs of peritonitis, without significant associated diseases, who can tolerate oral intake, can be treated at home with oral antibiotics (rifaximin)
How are patients with severe symptoms of uncomplicated symptomatic diverticulosis treated?
Those with severe symptoms should be hospitalized for establishment:
Digestive rest
Parenteral hydration
Administration of IV antibiotics
What determines the medical management of acute diverticulitis?
The degree of the patient’s symptoms.
The severity of diverticular disease.
In what situations are intravenous antibiotics and hospitalization required for diverticulitis?
Patients unable to tolerate an oral diet.
Patients with severe comorbidities.
Advanced age.
Immunosuppression.
Patients for whom oral antibiotics have been ineffective.
How is uncomplicated diverticulitis typically treated?
Oral antibiotics (ciprofloxacin or metronidazole).
A liquid diet.
What factors determine the treatment of complicated diverticulitis?
The severity of illness.
CT findings.
What are the general goals of diverticulitis treatment?
Administration of antibiotics (covering Gram-negative bacteria and anaerobes).
Putting the colon at rest.
Influencing algic symptomatology (pain relief).
Combating the infectious process.
Hydroelectrolytic rebalancing.
What is the treatment for mild forms of diverticulitis?
Ingestion of hydrosaccharate fluids.
What is the treatment for severe forms of diverticulitis (with repeated vomiting and subocclusive syndrome)?
Nasogastric suction probe.
Local ice bag.
Administration of hydroelectrolytic and caloric needs IV.
What is the preferred treatment for a stable patient with an approachable abscess, but without peritonitis or sepsis?
Percutaneous CT or US guided drainage.
Antibiotic (AB) therapy.
Total parenteral nutrition.
What are the conditions for “cold” surgery in diverticulitis?
Resection of the affected segment, followed by intestinal anastomosis.
How are small abscesses related to diverticulitis treated?
With intravenous antibiotic therapy and digestive rest.
How are larger abscesses related to diverticulitis treated?
Tomographic/ultrasound-guided percutaneous drainage.
Followed by selective single-stage surgery.
What is the surgical approach for multiloculated or inaccessible abscesses, or those with peritoneal signs?
Surgery from the beginning, generally in two steps.
Diversionary colostomy and Hartmann’s pouch are performed.
After healing, the colostomy is closed and reanastomosis is performed.
What are the initial steps in managing diverticular hemorrhage?
Parenteral correction of hypovolemia.
Parenteral correction of acute anemia.
What is the initial diagnostic procedure performed when diverticular hemorrhage occurs?
Colonoscopic exploration to specify the location and origin of bleeding.
What is the initial hemostatic intervention during colonoscopy for diverticular hemorrhage?
Hemostasis in situ by injection of Adrenaline.
What is indicated in cases of persistent diverticular hemorrhage after initial colonoscopic hemostasis?
Angiography.
What are the interventions performed during angiography for persistent diverticular hemorrhage?
Intraarterial administration of Vasopressin (hemostatic vasoconstrictor effect).
Embolization with Gelfoam.
What surgical procedure is indicated if continuous diverticular hemorrhage persists despite angiography?
Segmental colectomy.
How does diet affect the risk of complications in symptomatic diverticulosis?
Enrichment of the diet with vegetable fibers decreases the risk towards an unfavorable evolution.
What is a particular consideration regarding NSAIDs in elderly patients with diverticulosis?
Elderly patients should avoid NSAIDs as they increase the risk of perforation.
What immunosuppressive treatment is preferred in kidney transplant patients with diverticulosis, and why?
Cyclosporine is preferred over corticotherapy because it has a lower risk of perforation.
When is elective segmental resection surgery recommended for diverticulitis?
In young patients with recurrent episodes of diverticulitis or digestive hemorrhage.
