Diverticular Diseases (Diverticular Bleeding, Diverticulosis and Diverticulitis)

Question 1

What is diverticulosis?

Answer 1

little out-pouchings (could be one or many) of the wall of the bowel.

Question 2

Where is the most common place for diverticulosis (out-pouchings) to occur?

Answer 2

sigmoid colon

Question 3

Is it common to see diverticulosis in young individuals?

Answer 3

NO. Rather more than half of all people over the age of 80 have diverticulosis.

Question 4

Is diverticulosis normally asymptomatic?

Answer 4

YES

Question 5

What happens if a diverticuli becomes plugged?

Answer 5

it can become inflamed (due to bacteria trapped within it), leading to diverticulITIS.

Question 6

What is complicated diverticulitis?

Answer 6

when these diverticuli progress to the point of perforation, leading to life or death situation.

Question 7

What can happen as a result of complicated diverticulitis (perforation of bowel)?

Answer 7

peritonitis (peritoneum becomes infected), abscess outside of the bowel, sepsis, fistulas.

Question 8

What is a fistula?

Answer 8

when the body tries to heal something, but it forms it’s own inappropriate passageway/tube.

Question 9

How does diverticulosis typically present?

Answer 9

painless lower GI bleeding (but MOST are completely asymptomatic)!
*bleeding is usually minor, but can be massive.

Question 10

Is diverticulosis one of the top 5 causes of massive lower GI bleed?

Answer 10

YES

Question 11

What is a hemoccult?

Answer 11

simple stool sample smear that is sent to the lab for testing.

Question 12

What pt data should you expect to find on H&P for diverticulosis?

Answer 12

1. Age greater than 40 (but especially elderly)
2. low fiber diet (due to heavy, massive stools that increase intraluminal pressure).
3. obesity
4. constipation

Question 13

What key findings should you expect to find on H&P for diverticulOSIS?

Answer 13

none other than a possible positive hemoccult.

Question 14

What diagnostic tests do we have for diverticulOSIS?

Answer 14

• labs= none
• imaging= none (although diverticuli are sometimes found incidentally on abdominal CT scan or barium enema performed for other reasons).
• endoscopy= COLONOSCOPY (or ANGIOGRAPHY preceded sometimes with radionuclide scan, if BLEEDING is PROFUSE).
• KNOW PICTURES of diverticulosis.

Question 15

What is the typical presentation of a pt with diverticulITIS?

Answer 15

1. LLQ focal abdominal tenderness (usually crampy, though diverticulitis of the right colon can mimic appendicitis). Remember LLQ bc the sigmoid colon is the most common place.
2. fever
3. constipation (secondary to ileus from sympathetic overstimulation) or diarrhea (due to inflammatory mediators causing edema and accumulation of fluid).
4. bloating and flatulence (due to retention of gases).
5. +/- nausea and vomiting (in complicated diverticulitis).
6. +/- generalized abdominal pain (in complicated diverticulitis).

Question 16

What are the key histories/pt data to see on H&P in a pt with diverticulITIS?

Answer 16

• PMHx of diagnosed diverticulosis (or history of bleeding).

Question 17

What other findings will you find on a pt presenting with COMPLICATED diverticulITIS?

Answer 17

• rebound tenderness and guarding (if complicated).
• +/- tender palpable mass
• tympani on auscultation
• decreased or absent bowel sounds

Question 18

** Will elderly pts (65 and older) on steroids have few if any complaints or pain-related findings on PE for complicated diverticulITIS? (TEST QUESTION)

Answer 18

YES

Question 19

What are the diagnostic tests for diverticulITIS?

Answer 19

• Labs= CBC (white count), blood culture (only if complicated), and hemoccult (typically NEGATIVE, but will become positive in complicated diverticulitis).
• Imaging= abdominal CT (see pericolic fat stranding, diverticuli, bowel wall thickening, and if complicated +/- abscesses, peritonitis, or fistulas).
• Endoscopy= NOT DURING AN ACUTE EVENT!!!

Question 20

In what areas of the bowel will you see diverticuli?

Answer 20

• areas where it is weakest; areas where the blood vessels permeate the entire wall thickness. This is why we often see bleeding.

Question 21

So what 2 things do we need to make a diagnosis of divertiulITIS?

Answer 21

1. ABDOMINAL CT (see picture)

2. COLONOSCOPY (AFTER inflammation has subsided).

Question 22

** How do we treat diverticulOSIS?

Answer 22

• go home and eat high fiber diet

Question 23

** How do we treat diverticulITIS?

Answer 23

• metronidazole with ciprofloxacin

Question 24

** How do we treat COMPLICATED diverticulITIS?

Answer 24

admitted to hospital and IV antibiotics