diverticulitis

Question 1

I. Epidemiology

b/w sexes
age
geography

who get’s diverticulitis

Answer 1

asymptomatic
roughly equal between sexes 
disease of western civilization
incidence increases with age
and there os a increasing prevalence over time

Question 2

what % of population has diverticulosis

Answer 2

2/3 of elderly have diverticulitis

Question 3

where does diverticulosis occur

Answer 3

Along the mesenteric sides of the anti-mesenteric taenia and along both sides of the mesenteric taenia

vascular penetration

Question 4

in the colon the long muscles are designed how

Answer 4

three bands of muscle
that attach to the mesentery
sends and brings back

Question 5

most of us get diverticulitis in our

Answer 5

sigmoid colon

but in asia most people have right sided diverticulitis

Question 6

how does elastin create diverticulitis

Answer 6

proteins in colon that contract
increase pressures
and pooch

higher pressures AFTER you eat

Question 7

which populations are prone to diverticulitis

Answer 7

people with connective tissues dz

Precocious diverticulosis occurs in patients with connective tissue disorders (Ehlers-Danlos, Marfan’s)

Question 8

Pathogenesis I Colonic Wall Resistance

Answer 8

> 200% increase in elastin deposition, laid down in contracted form, with shortening of taenia and ‘concertina-like’ bunching of circular muscle

more elastin more squeeze

a. No evidence that atherosclerosis or venous changes predispose

Question 9

mortality is higher fore this population with diverticulitis

Answer 9

b. Symptomatic pts have higher motility indices than asymptomatic patients

Question 10

Wynne-Jones theory

Answer 10

thesis is that the reason is because the westernized life style is “impermissive of flatus”

Question 11

diverticulosis

Answer 11

that state of having diverticula

Question 12

what types of BM prevent diverticulitis

Answer 12

high volume low pressure

Question 13

relationship between diverticulitis and starting a fiber diet

Answer 13

i. Those with higher fiber had less complicated disease

lower risk of complications by 30-40%

Question 14

inherited risk

Answer 14

40%

Question 15

poop stuck in diverticula

Answer 15

fecalith

Question 16

SUDD

Answer 16

XII. Symptomatic Uncomplicated Diverticular Disease (SUDD)

lower abdominal symptoms in absence of overt inflammation (by vital signs, labs, CT)

Question 17

c. Possible mechanisms SUDD

Answer 17

i. Inflammatory damage to enteric nerves (and aberrant re-innervation leading to visceral hypersensitivity)
ii. Altered neuropeptides
iii. Muscle hypertrophy with increased intraluminal pressure
iv. Microbiota alterations

Question 18

Cyclic Rifaximin

Answer 18

antibiotic that is not absorbed

Significant improvement in SUDD Sxs and greater prevalence of Sx-free patients at 1 year WITH fiber plus rifaximin in comparison with fiber alone.

Question 19

what type of probiotics should we use?

Answer 19

fermented food

Question 20

Mesalamine

Answer 20

Mesalamine - 1st line tx for ulcerative colitis
(IBD )
(Chrons and choelitis tx for inflammation )

People felt better but diverticulitis symptoms were not decreased. Mesalamine doesn’t really help

Question 21

Complicated diverticulosis - Diverticulitis

pathology

Answer 21

Inflammation and/or infection associated w/ diverticula
probably a perforation

Bacteria breach mucosa, through wall, and cause (often limited) perforation.

Affects <10% of patients with diverticula

Question 22

CM of diverticulitis

Answer 22

Pain and tenderness, usually LLQ, but in Asians or those with redundant sigmoids, can be RLQ or suprapubic.

Altered bowel habits
Anorexia, nausea, vomiting
Hematochezia rare
dysuria: sympathetic cystitis 
Fever common; shock or hypotension increase WBC common; no other labs routinely useful

Question 23

dx test for diverticulitis

Answer 23

i. CT scanning - most accurate
1. Abd & Pelvic scans; oral / rectal / IV contrast
2. Findings: pericolic infiltration of fatty tissues, wall thickening, abscess
3. Sensitivity and Specificity: 85-95%
4. Severe disease predicts complications and poor prognosis.

you can diagnose without it w/ hx of diverticulosis and LLQ pain

Question 24

TX for antibiotics

Answer 24

if you use anitbiotics

i. Antibiotics: cover gut organisms (eg GNRs & anaerobes, esp E. coli and bacteroides)
ii. Oral: consider T/S or cipro plus flagyl
1. Single agent: Augmentin
iii. IV: aminoglycoside/aztreonam/3rd gen ceph plus metronidazole or clindamycin.
1. Single agent: Unasyn
iv. Sxs should ß w/in 2-3 days, advance diet.
v. Continue Rx for 7-10 days

but you DON’T NEED TO

Question 25

how to determine hospitalization

Answer 25

1. Mild symptoms, no peritoneal signs, tolerating POs, & supportive home networks: may be candidates for outpatient Rx.
2. Elderly, immunosuppressed, comorbid illness, or evidence of severe disease (high WBC or fevers): inpatient Rx.

Question 26

when should you operate?

Answer 26

old: start after two attacks

now it’s after 3 or 4 attacks

Question 27

hemorrhage with diverticulitis

Answer 27

bright red
need to exclude
c. Exclude UGIB with NGT or EGD

Question 28

Complicated diverticulosis (Abscess)
suggested by

Answer 28

a. Suggested by persistent fever or WBC
i. The pocket popped and now there is a collection of pus
b. CT scan: diagnose & follow course

Question 29

stage I of diverticulosis complication

Answer 29

Stage I (small pericolic abscesses): 70-80% success with medical tx alone

Question 30

Complicated diverticulosis (Abscess) stage II

Answer 30

d. Stage II (distant abscesses):
i. CT-guided percutaneous drainage
ii. Allows for rapid control of sepsis without operative risk, allows for temporary drainage and single-stage procedure in 3-4 weeks.
iii. 15-25% may still require primary surgical therapy if multiloculated or inaccessible.

Question 31

Complicated diverticulosis are known as

Answer 31

(Fistulas)

Occur when phlegmon/abscess extends or ruptures into adjacent organ

i. One organ connecting another organ

Question 32

b. Colovesicular

Answer 32

(65%) 2:1 M:F (colon to the bladder)

i. fecaluria - pathognemonic
ii. pneumaturia - suggestive

Question 33

Colovaginal

Answer 33

Colovaginal: (25%) stool / flatus per vagina

d. Coloenteric, colouterine, colocutaneous: rare
e. Treatment: single-stage resection / closure

Question 34

Most common cause of LGIB

Answer 34

Diverticulitis

Most common cause of LGIB (30-50%)

Question 35

LGIB risk increases with

Answer 35

e. Increased risk with NSAID use.- antiplatelet agents

Question 36

Symptomatic Uncomplicated Diverticular Disease (SUDD) is characterized by

Answer 36

lower abdominal symptoms in absence of overt inflammation

Question 37

what can we use as a marker of inflammation in diverticular disease

Answer 37

Fecal calprotectin

elevated in SUDD and acute diverticulitis

Question 38

Complicated Diverticulosis (Diverticulitis) is generally the result of

Answer 38

the result of perforation of a single diverticulum.
o Probably due to obstruction by inspissated stool.

” Affects < 15% of pts with diverticula.

Question 39

H. Pylori is a Major factor leading to …

Answer 39

gastroduodenal dz, including PUD,
gastric CA, gastric mucosa-associated lymphoid dz (MALT) lymphoma
increase NSAID complications

controversial dyspepsia

Question 40

who to test for H PYLORI

Answer 40

Active or h/o of PUD
gastric MALT lymphoma
h/o of gastric cancer
uninvestigated hyspepsia <60
iron deficiency
pre-bariatric surgery
ITP
fhx gastric CA 
prior long term NSAID rx