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Snap Shot
  • A 65 year old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low grade fever, midabdominal distention, and lower left quadrant tenderness. Stool guiac is negative. An absolute neutrophillic leukocytosis and a shift to the left are noted on the CBC.
Introduction
  • Diverticulosis: presence of multiple acquired diverticula
  • Diverticulitis: infection and macroperforation
  • Most common cause of acute lower GI bleed in patients > 40
  • 50% of Americans develop diverticula
    • 10-20% symptomatic
  • Three times more common on left than the right
  • True diverticula:
    • rare herniation that involves full bowel wall thickness
    • found in ascending colon and cecum
  • False diverticula
    • common mucosal herniations through muscular wall
    • 90% in sigmoid
  • Risk factors are
    • low fiber high fat diet
  • Predisposes to bacterial overgrowth that can lead to a generalized malabsorption
Presentation
  • Diverticulosis 
    • often asymptomatic
    • LLQ pain and tenderness
    • GI hemorrhage
  • Diverticulitis
    • constipation
    • looks like apendicitis but on the left (N/V/F)
    • LLQ pain and tenderness
    • diarrhea
Evaluation
  • Labs
    • leukocytosis
  • Imaging
    • CT best at making diagnosis
    • AXR may show partial SBO or LBO
    • Low pressure barium studies can be used but perforation is a risk
  • Flexible sigmoidoscopy and barium enema contraindicated 
Differential
  • Must be distinguished from colorectal cancer
Treatment
  • Asymptomatic diverticular disease patients can be followed on a high fiber diet
  • Diverticulitis non-surgical management 
    • broad spectrum oral antibiotics
    • bowel rest
    • pentazocine for pain
  • If symptoms do not resolve then sigmoid colectomy 
    • primary resection with anastomosis or colostomy / anastamosis at later date
Prognosis, Prevention, and Complications
  • Bleeding
    • arterial, not venous
  • Colovesicular fistula
  • Perforation with peritonitis
  • Abscess formation
    • if < 3 cm, treat with IV antibiotics
    • if > 3 cm, treat with CT guided percutaneous drainage
  • Prevention
    • increase fiber intake 
 

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