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