Diverticular Disease Flashcards
When do you see more diverticulosis?
Increases with age (over 60 see more)
Predominant sight of diverticulosis
Sigmoid colon (smallest diameter and largest intraluminal pressure)
Most common presentation of diverticulosis
Asymptomatic and discovered incidentally
Why does diverticulosis occur?
Develops at weak point in the colonic wall where vasa recta penetrate
Increased pressure predisposes mucosa and submucosa to herniate
Also a low fiber diet–constipation–intraluminal pressure–herniation (progression maybe)
Other sxs of diverticulosis
Occasional abdominal cramping, constipation, diarrhea, bloating
Normal exam
Diagnostics for diverticulosis
No labs or imaging needed b/c usually found incidentally
Tx for asymptomatic diverticulosis
High fiber diet (20-35 g/day)-increase stool bulk
Adequate hydration
Don’t recommend avoidance of seeds/nuts
Why does diverticulitis occur?
Inspissated debris obstructs neck of diverticulum or increased luminal pressure result sin erosion of diverticular wall leading to inflammation and necrosis and then a perf (free air and peritonitis)
Most common type of diverticulitis
Uncomplicated
Types of complicated diverticulitis
Abscess, fistula, obstruction or perforation
Presentation of acute diverticulitis
Progressive, steady aching pain usually LLQ
Fever/chills
Maybe n/v, change in bowel habits, irritative urinary sxs
Low fever, maybe peritoneal signs
What can be seen with a colovesical fistula with diverticulitis?
Pneumaturia or fecaluria
Exam for diverticulitis
LLQ abd tenderness
Rectal exam may have mass or tenderness (stool guaiac)
Pelvic exam for women
Labs for diverticulitis
CBC-moderate leukocytosis (maybe not in elderly)
BMP/CMP (maybe amylase or lipase)
UA/culture and urine HCG
Stool studies if diarrhea
Test of choice for acute diverticulitis
CT scan of A/P with contrast (see localized bowel wall thickening and fat stranding, presence of colonic diverticula)
Other options for imaging for acute diverticulitis
Abd/CXR (for obstruction or perf)
U/s
Diagnostics contraindicated in diverticulitis
Flex sig/colonoscopy (risk of perf) Barium enema (can leak through perf and exacerbate peritonitis)
General tx for uncomplicated diverticulitis
Usually give oral abx
Clear liquid/low residue diet
Close f/u in 2 days
General tx for complicated diverticulitis
Admit
NPO, IVF, IV abx
Outpatient tx of uncomplicated diverticulitis
Gram negative/anaerobic coverage x 7-10 days
CL/low residue diet and advance as tolerated to high fiber diet (resolve acute episode)
Maybe repeat imaging
F/u in 2 days!!!
When is inpatient management done for diverticulitis?
Complicated on CT Significant leuokcytosis >102.5 F Severe of increasing abd pain Peritoneal signs Comorbidities/immunocompromised Can't tolerate PO Noncompliance/unreliability/lack of support Failed outpt tx Elderly
Inpatient tx of diverticulitis
NPO or CL depending on severity
IVF, analgesic
IV abx (transition to oral for a 10-14 day course)
When is repeat imaging done with an inpatient diverticulitis?
Failure to improve within 2-3 days of IV abx therapy
When to refer to surgery with acute diverticulitis?
Perforation with peritonitis
Condition deteriorates/fails to improve within 72 hrs of medical therapy
Complicated
Long term management of diverticulitis
High fiber diet when acute episode resolves
Colonoscopy 6-8 wks after resolution for some ppl (evaluate extent of disease or exclude concomitant colon cancer of IBD)
Common cause of overt lower GI bleeding in adults
Diverticular bleeding
Tx for diverticular bleeding?
Usually resolves spontaneously
Why does diverticular bleeding occur?
Penetrating artery draped over dome of diverticulum is easily exposed to injury and susceptible to bleeding
Where is diverticular bleeding seen the most?
Right colon (b/c diverticulum are wider and have more exposure of vasa recta)
Presentation of diverticular bleeding
Painless hematochezia
Maybe bloating, cramping, fecal urgency, abd vital signs pending severity
Usually normal exam but maybe TTP
Diagnostics for diverticular bleed
CBC (trend H/H)
BMP (BUN/Cr should not be elevated in pts with colonic diverticular bleed but upper GI will be)
How to locate source of bleeding for diverticular bleed
Flex sig/colonoscopy and maybe tagged RBC scan/angiography (after initial resuscitation)
Management of diverticular bleeding
Resuscitation/hospitilization and maintain BV (transfuse)
Tx of bleeding site: endoscopic therapy, angiographic therapy and maybe surgical intervention
