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

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