2- Diverticular disease

Question 1

What are defined as sac-like protrusions of the colonic wall?

Answer 1

Diverticulum/ diverticula

Question 2

What is defined as the presence of diverticula?

Answer 2

Diverticulosis

Question 3

What is defined as inflammation of a diverticulum?

Answer 3

Diverticulitis

Question 4

How does the prevalence of diverticulosis change with age?

Answer 4

Increases with age

Question 5

What portion of the colon is primarily affected by diverticulosis?

Answer 5

Sigmoid

Question 6

How does diverticulosis generally present clinically?

Answer 6

Asx, discovered incidentally, normal PE

(occasionally abd cramping, constipation, diarrhea, bloating)

Question 7

What is the pathophysiology of diverticulosis?

Answer 7

• Develop at weak points in colon wall
• Increased intraluminal pressure predispose mucosa and submucosa to herniate
• Low fiber diet → constipation → intraluminal pressure → herniation

Question 8

What are the complications of diverticulosis?

Answer 8

Diverticulitis, bleeding

Question 9

For pts who present with diverticulosis that clinically manifests as diverticulitis, are the majority simple or complicated?

Answer 9

Simple (85%)

Question 10

Are labs/ imaging typically required for diverticulosis?

Answer 10

No- most discovered incidentally on colonoscopy/ imaging

Question 11

How is asx diverticulosis managed?

Answer 11

High fiber diet (20-35 g/ day), adequate hydration

Question 12

What is NOT recommended for management of asx diverticulosis?

Answer 12

Avoidance of seeds/ nuts

Question 13

What is the pathophysiology of acute diverticulitis? (4 steps)

Answer 13

Debris obstructs diverticulum neck/ increased luminal pressure results in erosion of diverticular wall → inflammation/ focal necrosis → perforation (micro or macro) → free air/ peritonitis

Question 14

What is defined as intra-abdominal spread of bacteria/ fecal matter?

Answer 14

Peritonitis (emergency)

Question 15

What defines acute diverticulitis as complicated? (4)

Answer 15

Abscess, fistula, obstruction, perforation

Question 16

Pt presents with progressive, steady aching pain in the LLQ, fever/ chills, (+/- N/V, change in bowel habits, irritative urinary sxs, peritoneal signs, and tenderness on rectal exam). What are you concerned for?

Answer 16

Acute diverticulitis

Question 17

What are the causes of irritative urinary sxs (if present) in acute diverticulitis?

Answer 17

Pneumaturia (air in urine) or fecaluria (fecal matter in urine) if colovesical fistula

Question 18

If pt presents with sxs consistent with acute diverticulitis, what is important to review as part of their hx?

Answer 18

Prior hx of diverticulitis episodes

Question 19

If concern for acute diverticulitis, what exam should be performed in women?

Answer 19

Pelvic

Question 20

What lab diagnostics should be ordered if concern for acute diverticulitis?

If of childbearing age?

If diarrhea?

If occult blood?

Answer 20

CBC (leukocytosis), BMP/ CMP, UA/ urine culture

If of childbearing age → urine HCG

If diarrhea → stool studies

If occult blood → stool

Question 21

What is the test of choice for diagnostic eval of acute diverticulitis?

Answer 21

CT scan of AP w/ contrast

(localized bowel wall thickening/ fat stranding, colonic diverticula)

Question 22

Aside from CT of A/P with contrast (test of choice), what other imaging might be ordered for diagnostic eval of acute diverticulitis?

Answer 22

Abd/ chest x-ray, US

Question 23

What diagnostic studies are contraindicated for eval of acute diverticulitis?

Answer 23

Flex sigmoidoscopy/ colonoscopy (risk of perf)

Barium enema (leakage through perf and exacerbation of peritonitis)

Question 24

What is the management for uncomplicated acute diverticulitis?

Answer 24

Discharge home (+/- abx), clear liquid/ low residue diet, close f/u within 2 days

Question 25

What is the management for complicated acute diverticulitis?

Answer 25

Admit, NPO, IV fluids, IV abx, consult GI, surgery

Question 26

What is typically recommended for abx in the tx of acute uncomplicated diverticulitis?

Answer 26

G-/ anaerobic coverage x 7-10 days * Metro + Cipro * Metro + Bactrim * Augmentin * Modifloxacin (if tolerant to metro and beta-lactams)

Question 27

What are guidelines regarding repeat imaging for acute uncomplicated diverticulitis?

Answer 27

Not necessary if clinical improvement

Question 28

The following are indicative of what for acute diverticulitis? * CT shows complicated diverticulitis * Significant leukocytosis * High fever ( \> 102.5) * Severe/ increasing abd pain * Peritoneal signs * Comorbidites/ IMC * Inability to tolerate PO * Noncompliance/ unreliability/ lack of support * Eldely

Answer 28

Inpatient management

Question 29

What are guidelines regarding repeat imaging for acute diverticulitis with inpatient management?

Answer 29

Repeat imaging necessary if failure to improve within 2-3 days of IV abx therapy

Question 30

When treating acute diverticulitis with inpatient management, what is the protcol after IV abx therapy?

Answer 30

Transitioned to PO abx to complete a total of 10-14 day course

Question 31

When is surgical referral for management of acute diverticulitis indicated? (3)

Answer 31

* Perf w/ peritonitis * Deterioration/ failure to improve w/i 72 hrs of therapy * Complicated

Question 32

What is included as part of long-term management of acute diverticulitis?

Answer 32

High fiber diet once acute episode resolves Colonoscopy performed 6-8 weeks after resolution to eval extent of disease/ exclude colon CA/ IBD

Question 33

The decision to perform prophylactic colonic resection in patients with recurrent diverticulitis is based on what?

Answer 33

Individualized (if uncomplicated, may not be necessary)

Question 34

What is a common cause of overt lower GI bleeding in adults and usually resolves spontaneously?

Answer 34

Diverticular bleeding

Question 35

A penetrating artery draped over the dome of diverticulum leading to easy exposure to injury and susceptibility to bleeding is the pathophysiology for what?

Answer 35

Diverticular bleeding (R colon often source of bleed)

Question 36

Pt presents with painless hematochezia, TTP on abd exam, blood on rectal exam, +/- bloating/ cramping/ fecal urgency/ abn vital signs. What are you concerned for?

Answer 36

Diverticular bleeding

Question 37

What diagnostics should be ordered for initial eval of diverticular bleeding?

Answer 37

CBC, CMP, EGD/ NG lavage (BUN/Cr not elevated if colonic diverticular bleeding)

Question 38

Once initial resuscitation for diverticular bleeding is complete, what is the next step?

Answer 38

Locate source of bleeding with flex sig/ colonoscopy

Question 39

What is included in the management of diverticular bleeding?

Answer 39

**Usually self limited** but if necessary: Resuscitation/ hospitalization (maintain blood volume) Treatment of bleeding site (endoscopic therapy, angiographic therapy, +/- surgery)