Diverticulitis

Question 1

What quadrant does diverticulitis pain present?

Answer 1

LLQ - descending colon; large bowel

Question 2

What is diverticulitis?

Answer 2

Inflammation that results from stagnating fecal material in a single diverticulum. This produces a fecalith that leads to pressure necrosis of the mucosa and ultimately inflammation.

Question 3

What are the symptoms of diverticulitis?

Answer 3

Fever <102, anorexia, nausea, cramping, LLQ pain, constipation, board-like rigid abdomen w/ hypoactive bowel sounds (peritonitis)

Question 4

What labs abnormalities would you expect to see with diverticulitis?

Answer 4

Elevated WBCs
+FOBT if bleeding
CRP >170-200
Urinalysis - increased WBCs

Question 5

How can you determine if there is an abscess with diverticulitis?

Answer 5

Palpable mass

Question 6

What is the diagnostic test of choice for diverticulitis?

Answer 6

CT w/ contrast will give estimate of the degree of inflammation.
Obtain BUN/Cr before administering contrast

Question 7

When can you order a colonoscopy?

Answer 7

4-6 weeks after the acute episode has resolved to exclude malignancy.

Question 8

What are red flags symptoms of diverticulitis?

Answer 8

1. Increased age
2. Family/personal hx of colorectal cancer
3. Persistent symptoms despite treatment
4. Weight loss

Question 9

Diverticulitis management for mild outpatient cases.

Answer 9

Clear liquids for 2-3 days

AGA guidelines for abx

Question 10

Diverticulitis management for moderate to severe cases.

Answer 10

Hospitalization

Question 11

Antibiotic management for diverticulitis

Answer 11

Hold off if asymptomatic, no fever and not immunocompromised.

Metronidazole + Cipro OR Bactrim OR Levofloxacin

Augmentin alone

Question 12

Name 3 complications of diverticulitis.

Answer 12

1. Fistula
2. Abscess
3. Peritonitis

Question 13

What is one preventative measure for the recurrence of diverticulitis?

Answer 13

High fiber diet.

Question 14

A patient has intermittent left-sided lower abdominal pain and fever associated with bloating and constipation alternating with diarrhea. The provider suspects acute diverticulitis. Which tests will the provider order?

a. Barium enema examination
b. CT scan of abdomen and pelvis
c. Plain abdominal radiographs
d. Rigid sigmoidoscopy
e. Stool for occult blood

Answer 14

ANS: B, E
A CT scan of the abdomen and pelvis is the preferred imaging study if acute diverticulitis is suspected with diverticular abscess. Occult blood tests are necessary because uncomplicated diverticulosis is not known to cause occult rectal bleeding. Barium enema should be avoided in acute diverticulitis because of the risk of extravasation of barium into the peritoneal cavity, causing chemical peritonitis. Plain radiographs are not useful because they will appear normal. Rigid sigmoidoscopy usually cannot be performed beyond the recto-sigmoid junction, so is not useful.

Question 15

A patient has a history of diverticular disease and asks what can be done to minimize acute symptoms. What will the practitioner recommend to this patient?

a. Avoiding saturated fats and red meat
b. Consuming a diet high in fiber
c. Taking an anticholinergic medication
d. Using bran to replace high-fiber foods

Answer 15

ANS: B
Increasing dietary fiber reduces constipation and reduces the incidence of acute symptoms. Avoiding saturated fats and red meats does not reduce the risk of diverticulitis, but does decrease the risk of colon cancer. Anticholinergics and antispasmodics do not prevent attacks, but may help with symptoms. Bran may be used as an adjunct to high-fiber foods, but should not replace other high-fiber sources

Question 16

A patient with a history of diverticular disease experiences left sided pain and reports seeing blood in the stool. What is an important intervention for these symptoms?

a. Ordering a CBC and stool for occult blood
b. Prescribing an antispasmodic medication
c. Referring the patient for a lower endoscopy
d. Reminding the patient to eat a high fiber diet

Answer 16

ANS: C
Patients with suspected diverticular abscess of rectal bleeding need further evaluation and a referral for lower endoscopy is warranted. Hemorrhage is more common from the right colon. The other actions do not have priority over the need to evaluate the cause of bleeding.