Gastroenterology [DIVERTICULAR DISEASE] Diverticulosis Diverticulosis is the actual pocket - the physical outpouching of the colon caused by ↑ luminal pressure inside it. It’s typically the result of a diet rich in red meat and deficient in fiber. Repeated constipation causes the colon to contract against hard stool, resulting in ↑ pressures and eventually outpocketing of the colonic mucosa. It’s a very common condition in the United States that’s asymptomatic and often an incidental finding on routine screen. By eating a higher fiber diet and reducing red meat the disease and its complications (conditions listed below) can be prevented. Diverticuli are typically a disease of the elderly (> 50 yo). They occur more often on the left than the right because stool is harder on the left. They can be an incidental finding on CT scan, but are definitely diagnosed by colonoscopy.
Diverticuli. The normal colon (left) generates intraluminal pressures (the arrows) as a result of low fiber and chronic constipation. At select locations, the wall of the colon protrudes, stretching the mucosa (right) Spasm: Px: Diverticulosis + Continued Poor Diet Pt: Elderly pt + LLQ post prandial pain relieve with BM Dx: Clinical, Severe disease r/o Tx: High Fiber Diet
Diverticular Spasm = Symptomatic uncomplicated Diverticulosis This is caused by a spasm of the diverticulum - especially when diet hasn’t been changed. It will present as an LLQ postprandial pain that’s relieved by a bowel movement. The question stem will read like IBS but in an elderly patient. It’s treated with a high fiber diet to prevent future spasms. Diverticular Hemorrhage An arteriole in the dome of the diverticulum gets stretched, tears, and bleeds. This presents as a brisk, painless bleeding per rectum. It isn’t the FOBT of Iron Deficiency Anemia slow bleed – it’s a severe GI bleed with rapid blood loss. It’ll be diagnosed by first ruling out an upper GI Bleed (NG Tube / EGD) and found either on colonoscopy, tagged RBC scan, or Angiogram (see GI Bleeding for details). Diverticuli bleed from the right colon more often than the left (but diverticula occur on the left more than on the right). Diverticulitis Diverticulitis has a similar pathogenesis and presentation as a Left Sided Appendicitis of the elderly. A fecalith forms across a diverticulum causing obstruction, inflammation, and the compromise of the blood supply to the diverticulum. This results in infection, inflammation, and perforation. The presentation is highly variable - from a mild inflammation (low fever, mild leukocytosis, and abdominal tenderness) to florid peritonitis or perforation (high fever, massive leukocytosis, rebound, guarding). Diagnosis is made by first ruling out a surgical emergency with a KUB to ensure no free air or ileus, then via a CT scan to identify the extent of the disease. Avoid Colonoscopy until 2-6 wks after acute disease has resolved (to minimize the risk of perforation). Treatment is dependent on the severity. Mild Dz is treated with oral antibiotics and adequate bowel rest (liquid diet only). In more severe disease use NPO, IVF, and IV Antibiotics. Multiple combinations are acceptable as long as they get gram negatives and anaerobes (Ampicillin-Gentamicin and Metronidazole, Ciprofloxacin and metronidazole, OR pip/tazo). If there’s an abscess on the CT it needs to be drained. Finally, colectomy is indicated in severe or refractory disease.
Hemorrhage Px: Arteriole at the dome of diverticuli tears Pt: Elderly bright red bleed from rectum Dx: (1) r/o UGIB w/ NGT + EGD (2) Colonoscopy (Ø Bleeding) Arteriogram (Brisk Bleeding) Tagged RBC (Slow Bleeding) Tx: Embolization, Cautery, Resection
Diverticulitis Px: Diverticulitis + Fecalith + Perforation Pt: LLQ Pain in an elderly pt w/ acute onset and mild to severe fever + leukocytosis Dx: (1) r/o Perforation/Ileus with KUB (2) CT Scan for severity (3) Avoid Colonoscopy Tx: Mild = PO FQ + MTZ + Liquid Diet Severe = NPO, IVF, IV Abx Abscess = Drainage Perforation, Refractory = Colectomy Peritonitis
Fecalith, obstruction, infxn, inflammation
LLQ Abd Pain Perforation
Free Air
KUB
Surgery
Air-Fluid Levels Normal
Obstruction Surgery
Colon Mild Mild Dz Liquid Diet PO MTZ + FQ
CT Scan
Severe
Abscess Abscess
Severe Dz NPO, IV Abx, IVF, Amp-Gen + MTZ Cipro + MTZ
NPO, IV Abx, IVF, Drainage
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