Diverticular Disease Flashcards
Diverticulosis
presence of diverticula
Diverticulitis
inflammation of diverticulum
Epidemiology of diverticulosis
increases w/ age
asymptomatic/incidental finding
diverticulosis primarily involves
sigmoid colon
Pathophys of diverticulosis
develop at weak points in colonic wall where vasa recta penetrate; increase intraluminal pressure predisposes mucosa and submucosa to herniate
low fiber diet —> constipation – intraluminal pressure –> herniation
Presentation of diverticulosis
asymptomatic - incidental finding
complications: diverticulitis and bleeding
occasional abdominal cramping, constipation, diarrhea, bloating
normal PE
Dx of diverticulosis
none
most found incidentally on colonoscopy/imaging
Management of diverticulosis
High fiber diet (20-35 g/day)
Hydration
Role of fiber in diverticulosis
increases stool bulk reducing work of colon for BM
What is acute diverticulitis?
symptomatic episode corresponding to inflammation of a diverticulum
Pathophys of diverticulitis
inspissated debris obstructs the neck of the diverticulum or increased luminal pressure results in erosion of diverticular wall –> inflammation and focal necrosis –> perforation
Macroperforation can cause
free air
peritonitis
Types of diverticulitis
uncomplicated (most common)
complicated: abscess, fistula, obstruction, perforation
Signs of complicated diverticulitis
abscess
fistula
obstruction
perforation
Sx of acute diverticulitis
Progressive, steady aching pain (typically LLQ) *
Fever and/or chills
+/- Nausea/vomiting
+/- Change in bowel habits
+/- Irritative urinary symptoms
Pneumaturia or fecaluria if colovesical fistula*
+/- peritoneal signs
LLQ abdominal tenderness (maybe mass)
normal or abnormal BS
rectal exam may reveal mass/tenderness (obtain stool guaiac)
pelvic exam in women
Important to review prior hx of diverticulitis episodes*
Labs for acute diverticulitis
CBC - mid/mod leukocytosis (absent in elderly) BMP/CMP \+/- Amylase/Lipase UA/Urine culture HCG in women of childbearing age stool studies if diarrha Stool for occult blood
Dx of acute diverticulitis
CT scan of A/P w/ contrast (TEST OF CHOICE)***
- bowel wall thickening/fat stranding
- presence of diverticula
- assess for complications
- findings may be similar to carcinoma
Abdominal/Chest x-ray (nonspecific) - obstruction/perforation
US
Contraindicated in acute diverticulitis
Flex Sig/Colonoscopy - risk of perforation
Barium enema- barium could leak through perforation and exacerbate peritonitis
Tx for uncomplicated diverticulitis
home w/ oral abx
- gram negative/anaerobic coverage x 7-10 days
CL/low residue diet - advance as tolerated to high fiber
close f/u within 2 days!
no repeat imaging needed in those who continue to improve
F/u for uncomplicated diverticulitis
within 2 days
Tx for complicated diverticulitis
Admit
NPO, IVF
Analgesics
IV abx- transition to PO to complete a total of 10-14 day coarse
Consult GI, Surgery
Repeat imaging if failure to improve w/i 2-3 days of IV abx
Tx coarse for uncomplicated diverticulitis
gram negative/anaerobic coverage x 7-10 days
Criteria for inpatient management
- CT shows complicated diverticulitis
- Significant leukocytosis
- High fever > 102.5°F
- Severe or increasing abdominal pain
- Peritoneal signs
- Significant comorbidities / Immunocompromised
- Inability to tolerate PO
- Noncompliance/unreliability/lack of support system
- Failed outpatient treatment
- Elderly
Surgery criteria for diverticulitis
- perforation w/ peritonitis (absolute indication)
- condition deteriorates/fails to improve w/i 72 hours of medical therapy
- complicated
