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Diverticular Disease

Diverticulosis, Diverticulitis, Diverticular hemorrhage

definition of diverticulum a sac-like protrusion of the bowel (or GI tract) involving the mucosa and submucosa, pseudoherniation
diverticula locations most common site is colon (descending and sigmoid), also duodenum (Meckel's) and esophagus (Zenker)
Meckel's diverticulum primarily pediatric, rule of 2's (2% of population affected, 2 feet from ileocecal valve, 2 inches in length, 2% are symptomatic)
Meckel's diverticulum symptoms unexplained lower GI bleeding, ectopic gastric (or pancreatic) mucosa in the diverticulum (50% of Meckel's have gastic/pancreatic cells)
Meckel's scan detects gastric mucosa w/in duodenal diverticulum
diverticulosis flow-chart 70% are asymptomatic, 5-15% have bleeding, 15-25% develop diverticulitis, prevalence increases with increasing age
diverticulitis flow-chart 75% have simple diverticulitis, 25% have complex diverticulitis (abscess, obstruction, fistula, and/or perforation)
anatomy of diverticula pseudoherniation, involves mucosa and submucosa, doesn't involve muscularis layer, usually located in descending colon, size: 5 mm - 2 cm
definition of diverticulosis herniation of mucosa and submucosa through the muscular layers of the colon
definition of diverticulitis inflammation of diverticula
diverticulosis etiology evolving ideas, RFs include: low-fiber diet; small, hard stools; increased intraluminal pressure; perhaps obesity
uncomplicated diverticulosis comprises 85% of diverticular dz; mostly asymptomatic; sxs are mild and vague, may include: LLQ pain; pain worse w/eating; pain improved w/defecation or flatus; bloating; constipation; diarrhea
complications of diverticulosis obstruction (as in inflammation), hemorrhage, perforation (micro- or larger), fistulas, diverticulitis
diagnostic tests for diverticulosis used to r/o other diseases; barium enema (can visualize diverticula, most commonly in descending and sigmoid colon); colonoscopy (risk of perforation)
prevention of diverticulosis high-fiber diet or fiber supplement; little evidence supporting avoidance of seeds, nuts, popcorn, corn, etc.
diverticulitis inflammation of diverticula, 15-25% of diverticulosis patients, involves microperforation of diverticulum wall (degree of perf. determines presentation and treatment)
stages of diverticulitis microperforation, localized paracolic inflammation, macroperforation (can include abscess or generalized peritonitis)
symptoms of diverticulitis mild-moderate ab. pain (LLQ usually, can present like appendicitis if in RLQ), intermittent or constant pain, crampy or sharp pain, constipation or diarrhea, anorexia, N/V, bleeding (hematochezia is rare), confounding symptoms (urinary sxs)
signs of diverticulitis low-grade fever, LLQ tenderness (most common sign), LLQ palpable mass, decreased bowel sounds
dx of mild-moderate diverticulitis clinical dx; CBC (WBCs may be elevated); plain radiography to r/o other causes
dx of moderate-severe diverticulitis applies also to patients who exhibit no improvement after 72 hours of treatment; CT scan
outpatient medical management of diverticulitis bowel rest, abx for broad-spectrum and anaerobic coverage, and close follow-up
abx for outpatient diverticulitis metronidazole + ciprofloxacin or Bactrim; if allergic to these, can use Augmentin
outpatient characteristics low fever; minimal increase in WBCs; able to eat and drink; otherwise healthy
inpatient medical management of diverticulitis NPO; IV fluids; abx for anaerobic and gram-negative coverage
abx for inpatient diverticulitis (CMDT: 2nd-generation cephalosporin); piperacillin-tazobactam; ticarcillin-clavulanate; metronidazole + 3rd-generation cephalosporin or quinolone; ampicillin-sulbactam
inpatient characteristics high fever; increased WBCs; intractable vomiting; elderly; immunocompromised
surgical management of diverticulitis 20-30% of patients will need; consult after 72h of conservative tx; emergent referral for free peritonitis, large abscess, or significant hematochezia; elective referral for fistula, chronic obstruction, or recurrent infx
diverticulitis outcomes 70-80% improve w/only medical tx; 15-30% require surgery; 30% recurrence risk
diverticular hemorrhage rare; usually R-sided (ascending colon); often no hx of acute diverticulitis; profuse arterial bleeding
symptoms of diverticular hemorrhage abrupt/acute onset; painless; profuse; mild cramping; urge to defecate
physical exam for diverticular hemorrhage hematochezia = massive rectal bleeding
dx of diverticular hemorrhage sigmoidoscopy or colonoscopy; tagged RBC scan; antiography
tx of diverticular hemorrhage usually none (usually spontaneously stop); watch closely!; hemodynamic support; cautery; intravascular vasopressin; resection
diverticular hemorrhage outcome 20-40% of patients rebleed; follow-up w/colonoscopy to r/o other causes
Created by: Carrie D.