Chapter 47: Colon and Rectum- Diverticulitis

Question 1

What is it?

Answer 1

Infection or perforation of a diverticulum

Question 2

What is the pathophysiology?

Answer 2

Obstruction of diverticulum by a fecalith leading to inflammation and microperforation

Question 3

What are the signs/symptoms?

Answer 3

• LLQ pain (cramping or steady)
• change in bowel habits (diarrhea)
• fever
• chills
• anorexia
• LLQ mass
• nausea/vomiting
• dysuria

Question 4

What are the associated lab findings?

Answer 4

Increased WBCs

Question 5

What are the associated radiographic findings?

Answer 5

On x-ray:

• ileus
• partially obstructed colon
• air-fluid levels
• free air if perforated

On abdominal/pelvic CT scan:

• swollen
• edematous bowel wall
• particularly helpful in diagnosing an abscess

Question 6

What are the associated barium enema findings?

Answer 6

Barium enema should be avoided in acute cases

Question 7

Is colonoscopy safe in an acute setting?

Answer 7

No, there is increased risk of perforation

Question 8

What are the possible complications?

Answer 8

• Abscess
• diffuse peritonitis
• fistula
• obstruction
• perforation
• stricture

Question 9

What is the most common fistula with diverticulitis?

Answer 9

Colovesical fistula (to bladder)

Question 10

What is the best test for diverticulitis?

Answer 10

CT scan

Question 11

What is the initial therapy?

Answer 11

• IV fluids
• NPO
• broad-spectrum antibiotics with anaerobic coverage
• NG suction (as needed for emesis/ileus)

Question 12

When is surgery warranted?

Answer 12

• Obstruction
• fistula
• free perforation
• abscess not amenable to percutaneous drainage
• sepsis
• deterioration with initial conservative treatment

Question 13

What is the lifelong risk of recurrence after:

First episode?

Answer 13

33%

Question 14

What is the lifelong risk of recurrence after:

Second episode?

Answer 14

50%

Question 15

What are the indications for elective resection?

Answer 15

• Case by case decisions but usually after two episodes of diverticulitis
• should be considered after the first episode in a:
  
  • young
  • diabetic
  • or immunosuppressed patient
  • or to rule out cancer

Question 16

What surgery is usually performed ELECTIVELY for recurrent bouts?

Answer 16

One-stage operation: resection of involved segment and primary anastomosis (with preoperative bowel prep)

Question 17

What type of surgery is usually performed for an acute case of diverticulitis with a complication?

Answer 17

Hartmann’s procedure:

• resection of involved segment with an end colostomy and stapled rectal stump

Resection, primary anastomosis loop ileostomy

Question 18

What is the treatment of diverticular abscess?

Answer 18

Percutaneous drainage; if abscess is not amenable to percutaneous drainage, then surgical approach for drainage is necessary

Question 19

How common is massive lower GI bleeding with diverticulitis?

Answer 19

Very rare! Massive lower GI bleeding is seen with diverticulosis, not diverticulitis

Question 20

What are the most common causes of massive lower GI bleeding in adults?

Answer 20

Diverticulosis (especially right sided), vascular ectasia

Question 21

What must you rule out in any patient with diverticulitis/diverticulosis?

Answer 21

Colon cancer