L7: Diverticular Disease Flashcards
The most common location of the Diverticulosis?
sigmoid colon
Factors that increase likelihood of Diverticulosis
Age
Connective tissue disorders: Marfan, Ehlers-Danlos
Progression of Diverticulosis
Low fiber diet→ constipation→ intraluminal pressure→ muscular hypertrophy→ mucosa/submucosa predisposed to herniate
Complications of diverticulosis
Bleeding
Diverticulitis
Presentation of diverticulosis
Generally asymptomatic, discovered incidentally
+/- abdominal cramping,C/D, bloating
+/-normal exam
How do you manage the asymptomatic diverticulosis patient?
High fiber diet:
0-35 g/days)
Increases stool bulk reducing work of colon for bowel movement
Adequate hydration
What used to be part of the treatment for asymptomatic diverticulosis, but no longer is?
(paradigm shift)
Avoiding seeds and nuts
Diverticulitis progression/pathophysiology
Insipissated debris obstructs the neck of the diverticulum or increased luminal pressure→ erosion of diverticular wall→ inflammation and focal necrosis→ perforation
→ microperforation
→ macroperforation→ +/- free air/peritonitis
A patient comes in complaining of progressive, steady, achy LLQ pain, fever, and change in bowel habits. On exam they (might) have peritoneal signs. DRE (might) show a mass or tenderness.
Diverticulitis
“Complicated” diverticulitis
Abscess
Fistula
Obstruction
Perforation
A diverticulitis patient comes in complaining of irritative urinary symptoms such as pneumaturia or fecaluria, what do they have?
Colovesical fistula
Definity don’t do these diagnostic studies for diverticulitis
Flex sig/colonoscopy→ risk of perforation
Barium enema→ barium leaks→ exacerbate peritonitis
Labs for diverticulitis
CBC→ +/- mild to moderate leukocytosis (absent in elderly) BMP/CMP \+/- amylase/lipase UA/urine culture Urine HCG Diarrhea→ stool studies Stool for occult blood
Imaging for diverticulitis
CT scan of A/P with contrast (test of choice)
localized bowel wall thickening (sigmoid mesocolon)/fat stranding
induration of perisigmoid fat
presence of colonic diverticular
+/- complications, other causes
findings may be difficult to distinguish from carcinoma
Abdominal/Chest xray→ nonspecific, obstruction or perforation
Ultrasound
Diverticulitis presentations that have to be admitted
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
Diverticulitis that needs to be referred to surgery
Perforation with peritonitis
Complicated
Deteriorates or fails to improve within 72 hours of tx
Treatment of uncomplicated diverticulitis
+/- Oral abx→ paradigm shift– selective vs routine use
G-/anaerobic coverage x 7-10 days
Clear liquids/low residue diets→ advance as tolerated to high fiber diet after resolution
Follow up in 2 days
Call for worsening symptom
Treatment of complicated diverticulitis
abscess, fistula, obstruction, perforation
Admit→ Consult GI, surgery
NPO, IV fluids + abx→ transition to PO x 10-14 days
Analgesics
IV abx 2-3 days w/o improvement→ repeat imaging
You’ve successfully treated your patient for diverticulitis so don’t forget to…
Do a Colonoscopy 6-8 weeks after tx
evaluate extent of diverticular disease exclude concomitant colon cancer or IBD
+/- Elective prophylactic colonic resection if recurrent (optional→ paradigm shift)
Diverticular bleeding prognosis
usually resolves spontaneously
Diverticular bleeding pathophysiology
Penetrating artery draped over dome of diverticulum→ easily exposed to injury
Usually right colon→ diverticulum are wider and more exposure of vasa recta
Painless hematochezia=
Diverticular bleeding
Presentation of diverticular bleeding
*Painless hematochezia* \+/- bloating, cramping, fecal urgency \+/- abnormal vital signs Normal abdominal exam +/- TTP Blood on rectal exam
Labs for diverticular bleeding
CBC→ trend H/H
BMP→ BUN/Cr should not be elevated
