Diverticular Disease

What is painful diverticular disease?

NOT SICKNESS BUT DISCOMFORT -MORE COMMON than diverticulitis or hemorrhage -Attacks of abdominal pain with no evidence of inflammation -Usually colicky pain -Pain INCREASES with eating (adding pressure) -Pain DECREASES With bowel movement or flatus (removing pressure) -Change in bowel habits, especially constipation

When do hemorrhages occur in diverticular disease?

Occur b/c diverticula are weak where vessels enter the colonic wall Usually large volume lower GI bleed arising from a diverticulum

How many people with sx with diverticular disease have diverticulitis? Painful diverticular disease?

Of those that are symptomatic: 75% have painful diverticular disease 25% have diverticulitis or hemorrhage

What is diverticulitis?

SICKNESS, FEVER, AND PAIN -Stool becomes impacted in the diverticulum and causes an inflammatory reaction (bacteria, enzymatic activity, cytokine production, etc.) -Complications can occur including RUPTURE due to local damage from inflammation (peritonitis can occur as bacteria spill out leading to pain, fever, etc.)

What section of the colon usually has diverticula?

Sigmoid colon involved 99% of the time

What is the treatment of large abscess or acute abdomen or recurrence?

Surgical consult for resection

What increases your risk of diverticulitis?

The MORE diverticula you have!

What imaging should be done on a patient with potential diverticular disease?

ABDOMINAL CT IS TEST OF CHOICE Will see... -Thickened bowel wall -Abscess -Diverticula

What is a risk factor for diverticula?

Industrialization and processing food

What is diverticulosis?

MANY DIVERTICULI ( with varied sizes) Usually asymptomatic (not an issue in and of itself)

What is the DDX for diverticular disease sx?

-Bacterial colitis -Ischemic colitis -IBD -Acute abdomen, consider small bowel obstruction (SBO), appendicitis, etc. -In women ectopic pregnancy and PID

What is the treatment for mild-moderate diverticulitis?

-Can resolve w/o antibiotic (controversial) -Cover gram - aerobes, and anaerobes Antibiotic regimens: -Cipro PO + Metronidazole PO -TMP/sulfa PO + Metronidazole PO -Amox/ Clavulanate PO

What are complications of diverticular disease?

-Colonic stricture -Bleeding -Fistulas to small bowel, colon, bladder, vagina -Recurrence in 1/3-> consider surgical resection at that point

What is the best way to dx painful diverticular disease?

-Colonoscopy -MUST R/O NEOPLASIA -Special care with colonoscopy because increased risk of perforation if diverticulitis present

What would be seen on plain films if the patient potentially has a diverticular disease?

-Displacement of colon -Free air under the diaphragm (if perforated ) -Mucosal abnormalities

What is the treatment for painful diverticular disease?

-High fiber diet -Increased fluids -Increased activity

What are the most common symptoms of diverticular disease?

-LLQ (sigmoid) pain (can also be felt on right side) -Fever in 60% -Leukocytosis in 80% -Constipation or loose stool possible -Suprapubic pain -NO RECTAL BLEEDING -If high fever/ sepsis can have peritonitis

How to diverticula develop?

-Low fiber in processed food -Prolongs transit time (poop in the colon longer) which increases intraluminal pressures -High intraluminal pressures cause diverticula to form

What percentage of people with diverticular disease have no sx?

>85%

What labs should be done on a patient with potential diverticular disease?

CBC -Leukocytosis Urinalysis -R/o upper tract UTI Fecal leukocytes (of diarrhea, to check for infection)

Can a colonoscopy be used in dx of diverticula disease?

CONTRAINDICATED if suspicion is high for diverticulitis because perforation could be exacerbated EXCELLENT to dx diverticulosis (just many, non-infected diverticula) in between attacks Do sigmoidoscopy if high suspicion of IBD or carcinoma

What are the manifestations of diverticular disease?

Diverticulitis or painful diverticula disease

What are diverticula?

Gaps between muscle layers or at entry points of blood vessels where the bowel wall is weakest

What is the treatment of severe diverticulitis?

HOSPITAL -Parenteral antibiotics Antibiotic regimens: -Cefoxitin IV -Piperacillin/ tazobactam IV -Ampicillin/ sulbactam IV -Cipro IV + Metronidazole IV

We get _________ diverticula as we age.

We get MORE diverticula as we age

Is intestinal perforation a big deal?

YES. SURGICAL EMERGENCY! *Look for free air under diaphragm*

Can a barium enema be used in dx of diverticula disease?

Yes it is safe. Can detect: Diverticula, spasm, perforation, and abscess