Diverticulosis/Diverticulitis

Question 1

What are the large bowel disorders?

Answer 1

Diverticular Disease
Irritable Bowel Syndrome
Constipation
Colon Polyps
Colorectal Cancer
Toxic Megacolon

Question 2

What is colonic diverticulosis?

Answer 2

Described as out-pouching of diverticula in colon

Question 3

What are the age characteristics of diverticulosis?

Answer 3

Colonic diverticulosis increases with age

>50% over age 80 years

Question 4

What are the general characteristics of diverticulosis?

Answer 4

Most are asymptomatic
1. Discovered incidentally on colonoscopy or barium enema

2. Vary in number & size from a few mm to several cm

Question 5

define diverticulosis

Answer 5

1. Diverticula present

2. Asymptomatic

Question 6

Define diverticulitis?

Answer 6

1. Inflamed diverticula

2. May cause potentially fatal obstruction, infection or hemorrhage

Question 7

What are the most common sites for diverticula?

Answer 7

1. Sigmoid colon

2. Descending colon

Question 8

What may be involved in complicated diverticulitis?

Answer 8

1. Abscess
2. Obstruction
3. Perforation
4. Fistula

Question 9

What is the etiology of diverticulosis?

Answer 9

Unknown

Question 10

What are contributing factors for diverticulosis?

Answer 10

1. Diminished colon motility & increased intraluminal pressure
2. Low fiber diet
3. Connective tissue disorders
   A. Scleroderma
   B. Marfan Syndrome

Question 11

What is the pathophys of diverticulosis?

Answer 11

1. Diverticula result from high intraluminal pressure on area of weakness in GI wall where blood vessels enter
2. Diet may be contributing factor
3. Insufficient fiber reduces fecal residue -> narrows bowel lumen -> leads to high intra-luminal pressure during defecation

Question 12

What are the sxs of diverticulosis?

Answer 12

1. Most asymptomatic
2. Some pts may have nonspecific complaints:
   A. Chronic constipation
   B. Abd pain
   C. Fluctuating bowel habits
3. Exam usually unremarkable

Question 13

What imaging is used for uncomplicated diverticulosis?

Answer 13

No imaging needed for uncomplicated disease

Question 14

True/false: colonoscopy is helpful in dx diverticulosis?

Answer 14

Colonoscopy less sensitive in detecting diverticula

Question 15

What imaging may be used for complicated diverticulosis?

Answer 15

Diverticula best seen on barium enema or CT abd & pelvis w/contrast

Question 16

What is the treatment for diverticulosis?

Answer 16

1. High fiber diet or fiber supplements reduce likelihood of complications
2. Avoid nuts/seeds

Question 17

What is diverticulitis?

Answer 17

Defined as inflammation of diverticula caused by obstructing matter

Question 18

Who is at risk for developing diverticulitis?

Answer 18

Patients with diverticulosis are at risk of developing diverticulitis

Question 19

What is the pathophys of diverticulitis?

Answer 19

1. Undigested food & bacteria accumulate in diverticular sac

2. Hard mass cuts off blood supply to thin walls of sac -> increased risk of infection

Question 20

What can untreated diverticulitis lead to?

Answer 20

increased risk of perforation

Question 21

What are the sxs of diverticulitis?

Answer 21

1. Abd pain
A. Sudden onset
B. Usually LLQ (site of tics)
2. +/- fever
3. Diarrhea OR constipation
4. N / V
5. +/- distention
6. Palpable tenderness
A. +/- mass in affected area
B. Guarding
C. +/- rebound tenderness
7. DRE may be tender

Question 22

What is the ddx for diverticulitis?

Answer 22

1. Perforated colon CA
2. Crohn’s Disease
3. Appendicitis
4. Ischemic colitis
5. C. Difficile colitis
6. GYN disorders
   A. Ectopic pregnancy
   B. Ovarian cyst
   C. Ovarian torsion

Question 23

What dx studies are used for diverticulitis?

Answer 23

1. Guaiac (+) stool common
2. Mild-mod leukocytosis
3. CT Abd/pelvis w/ contrast

Question 24

Who is a CT Abd/pelvis w/ contrast recommended for? Why?

Answer 24

1. Recommended in pts who do not respond to empiric therapy after 2-4 days
2. Evaluates extent of disease and R/O underlying colon CA

Question 25

Why should barium enema and colonoscopy be avoided in acute diverticulitis?

Answer 25

Barium enema & colonoscopy should be avoided during acute phase due to risk of perforation & peritonitis

Question 26

What are the results of a CT abd/pelvis with contrast in a pt with diverticulitis?

Answer 26

1. Colonic diverticuli & wall thickening: indicative of inflammation 2. Peri-colic fat infiltration 3. Abscess formation 4. Extraluminal air

Question 27

When is a colonoscopy or barium enema recommended for a pt w/ diverticulitis? Why?

Answer 27

1. Colonoscopy or BE done ≈ 6 weeks later A.R/O IBD or colon CA B. Evaluate extent of tics/obstruction risk

Question 28

What is the rx for mild diverticulitis?

Answer 28

1. Clear liquid / BRAT / Low residue diet 2. Add antibx if persistent A. Broad spectrum antibiotics x 7-10 days B. Fluoroquinolones/Ciprofloxin (Cipro) 500 mg po bid + Metronidazole (Flagyl) 500 mg po tid

Question 29

What is the rx for moderate diverticulitis?

Answer 29

1. Hospitalization & NPO 2. IV antibiotics x 5-7 days [gram (+), gram (-) & anaerobic coverage] A. Cefotaxime (Claforan) or piperacillin (Zosyn) OR B. Metronidazole (Flagyl) + ceftriaxone (Rocephin) 3. Bowel rest (NPO) 4. Analgesia 5. NG tube if ileus develops

Question 30

What is the tx for severe diverticulitis or refractory to treatment?

Answer 30

1. Surgery 2. Two stage procedure: A. Diseased colon resected, proximal colon brought out to form temp colostomy; distal stump closed B. 3-6 months later, after inflammation subsides, colon can be reconnected electively

Question 31

What are the indications for diverticulitis surgery?

Answer 31

1. Peritonitis 2. Large abscess 3. Fistulas 4. Obstruction