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Diverticular Disease: Qbank Session Clinical Sciences Learned
Diverticular Disease: Qbank Session Clinical Sciences Learned
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FEEDBACK
Definition
Diverticula: blind pouches that protrude from the gastrointestinal wall and communicate with the lumen
o True diverticulum: a type of diverticulum that affects all layers of the intestinal wall.
Rare (except Meckel diverticulum
)
Typically congenital
Most commonly occur in the cecum
Occur less commonly in the colon
o False diverticulum or pseudodiverticulum: type of diverticulum that involves only the mucosa and submucosa and does not contain muscular
layer or adventitia.
Most common type of gastrointestinal diverticula
Typically acquired
Diverticulosis: the presence of multiple colonic diverticula without evidence of infection [1]
Diverticulitis: inflammation or infection of colonic diverticula
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Epidemiology
In the US, ∼ 50% of individuals > 60 years have diverticulosis [2]
More common in high-income countries due to the higher prevalence of a high-fat, low-fiber diet
Epidemiological data refers to the US, unless otherwise specified.
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Etiology
Caused mainly by lifestyle and environmental factors
o Diet (low-fiber, rich in fat and red meat)
o Obesity
o Low physical activity
o Increasing age
o Smoking
Other causes: genetic factors
o Connective tissue disorders (e.g., Marfan syndrome, Ehler-Danlos syndrome) [1][3]
o Autosomal dominant polycystic kidney disease
References:[4][5]
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Pathophysiology
Diverticulosis: The formation of diverticula is considered multifactorial.
o Increased intraluminal pressure, e.g., due to chronic constipation
o Weakness of the intestinal wall
Age-related loss of elasticity of the connective tissue
Physiological gaps in the intestinal wall, which occur where blood vessels penetrate, predispose to protrusion and herniation of
intestinal mucosa and submucosa.
o Localized particularly in the sigmoid colon
Diverticulitis
o Most commonly: chronic inflammation and increased intraluminal pressure → erosion of diverticula wall → inflammation and bacterial
translocation
o Rarely: stool becomes lodged in diverticula → obstruction of intestinal lumen → inflammation
References:[6]
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Clinical features
Diverticulosis
Usually asymptomatic
May manifest with abdominal discomfort or pain, especially if associated with chronic constipation
Diverticulitis
Low-grade fever
Sigmoid colon most commonly affected → left lower quadrant pain
Possibly tender, palpable mass (pericolonic inflammation)
Change in bowel habits (constipation in ∼ 50% of cases and diarrhea in 25–35% of cases)
Nausea and vomiting (caused by bowel obstruction or ileus)
Acute abdomen: indicates possible perforation and peritonitis
↑ Urinary urgency and frequency (in ∼ 15% of cases)
In elderly or immunocompromised patients, clinical symptoms may only be mild.
References:[6][7]
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Diagnostics
Diverticulosis
Asymptomatic diverticulosis [8]
Typically an incidental diagnosis
No workup required
Symptomatic diverticulosis [9][10][11][12][13]
Colonoscopy: diagnostic modality of choice for suspected symptomatic diverticulosis
[12]
o Indications
Lower GI bleed
Recurrent abdominal pain and/or diarrhea
Concern for underlying malignancy
[13]
o Findings: well-defined outpouching from the colonic wall
o Avoid if acute diverticulitis is suspected.
o Biopsy and histological analysis can be performed, if necessary
Double-contrast barium enema: highly sensitive test to detect diverticulosis but not commonly performed
[9]
o Consider in the workup of the following: [10]
Recurrent LLQ pain without signs of acute inflammation
Altered bowel habits
Lower GI bleed in a hemodynamically stable patient if colonoscopy cannot be performed
o Contraindications: suspected diverticulitis or perforated diverticulum
[11][13]
o Findings: outpouching of the colonic wall of variable size
Abdominal ultrasound
o Indications: may be performed as part of the workup for nonspecific LLQ pain [11]
o Findings: outpouching from the colonic wall [13]
Colonoscopy is the diagnostic modality of choice for symptomatic diverticulosis.
Diverticulitis [14]
Suspect acute diverticulitis in adult patients presenting with LLQ pain, fever, and leukocytosis. The diagnosis is confirmed with imaging, preferably with
IV contrast-enhanced CT scan. Once the acute phase has resolved, a colonoscopy should be performed to rule out malignancy. Colonoscopy is
contraindicated in the acute phase because of the risk of perforation.
Laboratory studies [1][14][15]
Routine tests
o CBC: leukocytosis, possible anemia
o BMP: electrolyte abnormalities, ↑ BUN, ↑ creatinine
o CRP: ↑ CRP
o FOBT: positive in patients with diverticular bleeding
Imaging [11][14][15][16][17][18]
CT abdomen and pelvis with IV contrast [11]
o Indications
Preferred initial imaging modality for suspected diverticulitis
[11]
Staging the severity of diverticulitis
o Supportive findings
Colonic outpouching
Signs of inflammation
Bowel wall thickening > 3 mm
Peridiverticular mesenteric fat stranding
Complications may also be identified
Peridiverticular abscess: hypodense collections with peripheral contrast enhancement
Diverticular perforation: pneumoperitoneum
Intestinal obstruction: dilated intestinal loops with multiple air-fluid levels
Abdominal x-ray [15]
o Not useful in diagnosing uncomplicated diverticulitis
o Indications
Suspected perforation or bowel obstruction
May be performed as part of the routine workup for acute abdominal pain
o Findings that may be seen in complicated diverticulitis include
Bowel perforation: pneumoperitoneum
Bowel obstruction: dilated bowel loops and multiple air-fluid levels
Screening colonoscopy [14][15][17][19]
o Recommended 6–8 weeks after the resolution of the acute episode to assess the extent of diverticulitis and rule out malignancy [14]
o Colonoscopy is contraindicated during an acute episode because of the increased risk of perforation.
o Not required if a recent evaluation of the colon has been performed [19]
Avoid colonoscopy during the acute phase of diverticulitis because of the risk of perforation!
Classification of diverticulitis
To choose the best treatment approach and determine the prognosis, identifying the stage of acute diverticulitis is recommended. [15]
o Uncomplicated diverticulitis: localized inflammation of a colonic diverticulum with no evidence of complications
o Complicated diverticulitis: inflammation of a colonic diverticulum associated with complications such as perforation, abscess,
fecal peritonitis, bowel obstruction, or fistula formation [14]
The modified Hinchey classification is based on CT findings and is the most commonly used classification.
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Differential diagnoses
Differential diagnoses of uncomplicated acute diverticulitis
o Crohn disease, ulcerative colitis
o Colorectal cancer
o Intestinal ischemia (ischemic colitis)
o Acute appendicitis
o Ileus
, colonic obstruction
o Ectopic pregnancy
o Ovarian torsion
o Ovarian cancer
o Inguinal hernia
o Renal colic
o Urinary tract infection
Differential diagnoses of perforated diverticulitis: See gastrointestinal perforation.
See differential diagnoses of acute abdomen for a more comprehensive list.
The differential diagnoses listed here are not exhaustive.
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Treatment
Diverticulosis
Asymptomatic diverticulosis
o No treatment can reverse the growth of existing diverticula.
o The goal is the prevention of progression (see “Prevention of recurrence and disease progression” below).
Symptomatic diverticulosis: see “Treatment” in GI bleeding
Diverticulitis [13][18][21]
Approach
Uncomplicated diverticulitis
o Conservative management
[15][18]
o Consider broad-spectrum oral antibiotics (e.g., ciprofloxacin PLUS metronidazole) in select patient groups.
Complicated diverticulitis
o Inpatient management with broad-spectrum IV antibiotics is recommended.
o CT-guided percutaneous drainage for abscesses > 4 cm
o Emergency colectomy in patients with generalized peritonitis
Acute management
Uncomplicated diverticulitis
[15][18][21]
Antibiotic therapy: Not routinely recommended
[17][19][22]
o Indications [17][22][23]
Signs of generalized infection (e.g., fever)
Pregnancy
Immunosuppression
Comorbidities
o Consider one of the following commonly used broad-spectrum oral antibiotics [22][23]
Metronidazole
PLUS one of the following
Ciprofloxacin
Levofloxacin
Trimethoprim-sulfamethoxazole
Amoxicillin-clavulanate
Moxifloxacin
o See also empiric antibiotic therapy for intra-abdominal infections
o Duration of antibiotic therapy: 4–7 days [17]
Supportive care
o Relative bowel rest: clear liquid diet until improvement of symptoms
o Analgesics as needed (see acute pain management)
o Antiemetics as needed
Additional considerations
o Screening colonoscopy once symptoms have resolved.
o Consider elective colectomy for recurrent uncomplicated diverticulitis.
o GI consultation for patients with frequent, recurrent episodes or chronic symptoms [22]
Complicated diverticulitis
[17][18][19][21] [22]
Antibiotic therapy: broad-spectrum IV antibiotics are routinely recommended (see empiric antibiotic therapy for intra-abdominal infections)
Supportive care
o Complete bowel rest (NPO)
o IV fluids (see IV fluid therapy)
o Analgesics as needed (see acute pain management)
o Antiemetics as needed (see antiemetics)
Management of complications
o Abscess
[15][18][24]
Size ≥ 4 cm
Ultrasound- or CT-guided percutaneous drainage
Consider laparoscopic or open surgical drainage if percutaneous drainage is not feasible.
Continue IV antibiotic therapy.
Send aspirate or pus for cultures and tailor antibiotic treatment accordingly.
o Perforation with generalized peritonitis: emergency surgery [17][18]
Hemodynamically stable patients: laparoscopic or open colectomy and primary anastomosis with/without a temporary diverting stoma
Critically ill patients: Hartmann procedure
o Bowel obstruction
Additional considerations
o Inpatient treatment with surgery and/or IR consultation
o Screening colonoscopy once symptoms have resolved
o Consider elective colectomy if not performed during admission.
Subsequent management
Elective colectomy
[14][15][18][19]
Indications
o Routinely recommended 6–8 weeks after resolution of complicated diverticulitis
o Select groups of patients after resolution of uncomplicated diverticulitis, including:
[15][17][18]
Patients at high risk of recurrence with complications
[15]
Patients with persistent abdominal symptoms after resolution of an acute episode
o Chronic complications of diverticulitis (e.g., fistula, colonic strictures)
Procedure: laparoscopic or open colectomy
[15][17]
Diverticular bleeding [20][26]
o Epidemiology
Diverticulosis is the most common cause of lower GI bleeding in adults.
Occurs in ∼ 5% of individuals with diverticulosis
o Etiology: erosions around the edge of diverticula
o Clinical findings
Painless hematochezia
Severe or ongoing bleeding: significant drop in hemoglobin → hemodynamic instability (hypotension, tachycardia, dizziness,
reduced level of consciousness)
In 70–80% of cases, bleeding ceases spontaneously
o Differential diagnosis: other causes of lower gastrointestinal bleeding (e.g., hemorrhoidal bleeding)
o Treatment
Endoscopic hemostasis during colonoscopy (e.g., epinephrine injection, thermal coagulation, ligation)
Angiography with vessel embolization
Fistulas
[27]
o Colovesical (most common)
Symptoms
Pneumaturia and fecaluria
May cause recurring urinary tract infections, including urosepsis
Diagnosis: CT with oral contrast
Localized thickening of the colon and bladder
Air or contrast material in the bladder
Treatment
Resection and primary anastomosis
Antibiotics if surgery is not possible
o Other forms: colovaginal, coloenteric, colocutaneous
Inflammation (diverticulitis)
Abscess
o Peridiverticular localization
o Causes symptoms similar to those of acute diverticulitis
o Suspect an abscess in patients with persistent fever and abdominal pain despite antibiotic treatment.
Perforation
o Symptoms of acute abdomen caused by
Rupture of an inflamed diverticulum → free communication with the peritoneum → generalized fecal peritonitis
Rupture of a diverticular abscess → generalized purulent peritonitis
Intestinal obstruction
o Causes
Narrowing due to inflammatory swelling
Compression through abscesses
Ileus caused by localized irritation
o Symptoms
Abdominal pain and distention
Constipation
Nausea, vomiting
Acute abdomen