Diverticular disease Flashcards
What are diverticula
multiple sac like protrusions of the colon wall
Diverticulum is single
-osis vs -itis is
Diverticulosis: presence of diverticula
Diverticulitis: inflammation of a diverticulum
Where is diverticulosis and where/how does it present
MC in sigmoid colon (decreased diameter, increased pressure)
Prevalence increases with age
Usually discovered incidentally bc pts are ASx
What is the pathophys of diverticulosis
Develop at weak points in colon wall where vasa recta penetrate
Increased pressure predisposes mucosa to herniation
Low fiber diet= constipation= increased intraluminal pressure= herniation
What are clinical manifestations of diverticulosis
ASx
Occasional abdominal cramping, constipation, diarrhea, and bloating
but PE is totally normal
What are complications of diverticulosis
Diverticulitis (simple MC, or complicated) and bleeding
How do you diagnose diverticulosis
No labs or imaging needed!
MC discovered incidentally on colonoscopy or imaging
How do you manage ASx diverticulosis
**High Fiber Diet! 20-35g/d to increase stool bulk and reduce work of colon for a BM
Adequate hydration
(no longer have to avoid seed or nuts)
What is acute diverticulitis
Acute symptomatic episode corresponding to inflammation of diverticulum
What is the pathophys of acute diverticulitis
thick debris obstructs neck of diverticulum OR high pressure causes erosion of diverticular wall= inflammation and focal necrosis= perforation
What are the types of perforation
Micro and Macro
Macroperforation is a medical emergency 2/2 free are or peritonitis
What are the types of acute diverticulitis
Uncomplicated (*MC)
Complicated: abscess, fistula, obstruction, or perforation
What are clinical manifestations of acute diverticulitis
Progressive steady aching in LLQ (+/- mass)
Fever (low grade)
Rectal mass or ttp (get a guaiac)
+/- N/V, bowel habit changes, irritative urinary Sx, peritoneal signs (rebound, guarding)
Do a pelvic on women
A colovesical fistula can lead to
pneumaturia (gas in urine) or fecaluria
What is rigidity
involuntary hardening in response to an infection
What diagnostics should you get if you suspect acute diverticulitis
CBC: leukocytosis (absent in old ppl) BMP/CMP, Amylase Lipase UA/Urine culture Urine HCG in women Stool studies if it's diarrhea Stool for occult blood (DRE w/ guaiac test) **CT A/P WITH contrast** Can get abd/chest XR to assess for obstruction/perforation, but it is nonspecific US
What will a CT w/ show in acute diverticulitis
Local bowel wall thickening/fat stranding
Presence of colonic divertcula
(hard to tell this from carcinoma)
What diagnostics are contraindicated with suspected acute diverticulitis
Flex Sig, Colonoscopy: risk of perforation
Barium enema: barium can leak through perforation and exacerbate peritonitis
How do you treat Uncomplicated acute diverticulitis
Send home w/ oral antibiotics
Close follow up, 2 days
Low residue diet (advance to high fiber diet as tolerated)
Do not need repeat imaging if patient is improving
How do you manage complicated diverticulitis (or any inpt management)
Admit
NPO, IV fluids
IV antibiotics (transition to PO for 10-14d total)
Analgesics
Consult GI and surgery
Repeat imaging if no improvement in 2-3 days of IV Abx
What Abx are Rx to uncomplicated acute diverticulitis
Gram negative/Anaerobic coverage x 7-10 days
*Metronidazole 500mg PO TID + Ciprofloxacin 500mg PO BID
What would warrant inpt Tx of acute diverticulitis
Complicated Significant leukocytosis Fever >102.5 Severe/increasing pain Peritoneal signs Immunocompromised Can't tolerate PO Noncompliant Failed outpt Tx Elderly
Empiric Tx for high risk intra-abdominal infections are
Ertapenem or Zosyn (piper-Tazo) –or–
Cefazolin+Metronidazole
When does acute diverticulitis warrant surgical referral
Perforation with peritonitis
Condition deteriorates w/in 72 hours
Complicated (abscess, fistula, obstruction, perforation)
Criteria for acute diverticulitis discharge are
Vitals normal
Severe abdominal pain and leukocytosis resolve
Tolerate PO
Long term management of acute diverticulitis is
Once acute episodes resolve, high fiber diet*
Colonoscopy s/p 6-8 weeks resolution to eval extent of dz and exclude colon cancer/IBD (if they haven’t had one in a long time)
+/- prophylactic colonic resection (individualize)
What is a common cause of OVERT lower GI bleeding
Diverticular bleeding!
overt means you can see it.
Usually resolves spontaneously
What is the pathophys of diverticular bleeding
Penetrating artery overlies dome of diverticulum= susceptible to bleeding
Right colon is MC source of bleed 2/2 wider diverticulum w/ more vasa recta exposure
What are manifestations of diverticular bleeding
**Painless hematochezia
Abd exam usually normal (except ttp)
Blood on rectal exam
+/- bloating, cramping, fecal urgency, abn vitals
What diagnostics should you get in diverticular bleeding
CBC (trend H&H)
BMP (BUN/Cr not elevated)
END/NG lavage
Flex sig to locate bleeding AFTER initial resuscitation
How can you tell upper from lower GI bleed on a BMP
BUN:Cr is elevated in an upper GI bleed, and notmal in a lower GI bleed
How do you manage diverticular bleeding
Resuscitation, hospitalization (maintain blood volume, transfuse prn)
Tx bleeding site w/ Endoscopic therapy, Angiographic therapy, or surgical intervention (if needed)
