Snapshot A 63-year-old female is brought to the emergency room for severe abdominal pain for the past 1 day. She reports that the pain is 9/10, dull, with intermittent exacerbations concentrated at the left lower quadrant (LLQ). She endorses low-grade fever, nausea, and vomiting for the past couple of hours. Her past medical history includes hypertension, constipation, and diverticulosis. A physical examination demonstrates abdominal tenderness and some diffuse voluntary guarding. Introduction Clinical definition gastrointestinal disease characterized by the inflammation of diverticula results from a microscopic or macroscopic perforation of a diverticulum due to diverticular inflammation and focal necrosis patients can present with repeated attacks complicated diverticulitis is defined as diverticulitis with 1 of the following associated complications bowel obstruction abscess fistula perforation Epidemiology demographics most commonly occurs at the sigmoid colon in North America, reflecting the distribution of diverticulosis right-sided (cecal) diverticulitis is more common in Asian populations approximately 4% of patients with diverticulosis develop acute diverticulitis risk factors obesity lack of exercise smoking positive family history nonsteroidal anti-inflammatory drugs (NSAIDs) Pathogenesis primary process is thought to be due to erosion of the diverticular wall by increased intraluminal pressure or inspissated food particles erosions of the wall then lead to inflammation and focal necrosis that may lead to micro- or macroscopic perforation the inflammation is frequently mild and often walled off by pericolic fat and mesentery this may lead to the formation of a localized abscess or a fistula (if adjacent organs are involved) poor containment of the inflamed diverticulum or abscess can result in free perforation and peritonitis Presentation Symptoms abdominal pain most commonly at the LLQ nausea vomiting constipation diarrhea Physical exam fever hypotension tender mass peritoneal signs (e.g., guarding, rigidity, and rebound tenderness) Studies Diagnostic testing diagnostic approach diagnosis is based on clinical presentation and is confirmed via imaging studies imaging computed tomography (CT) with oral and IV contrast best diagnostic test positive findings include localized wall thickening (> 4mm), pericolic fat stranding, and presence of colonic diverticula also allows for visualizations of complications such as abscess, obstruction, or perforation abdominal ultrasound indicated in patients who cannot receive radiation positive findings include bowel wall thickening, hypoechoic peridiverticular inflammatory reaction, and the presence of diverticula abdominal and chest radiographs may be useful in detecting pneumoperitoneum and obstruction positive findings include air-fluid levels with bowel dilation or free air colonoscopy not to be performed during acute diverticulitis for risk of perforation recommended 4-6 weeks after resolution for evaluation and rule out of malignancy studies complete blood count may see leukocytosis urinalysis may see sterile pyuria or colonic flora (if colovesical fistula) pregnancy test indicated in all women of childbearing age Differential Inflammatory bowel syndrome (IBD) differentiating factors will often present with more chronic clinical symptoms and will have positive biopsy findings Colorectal cancer differentiating factors will be visualized on colonoscopy Acute appendicitis differentiating factors will appear differently on abdominal CT imaging Treatment Management depends on disease severity, certain characteristics, and the presence of complications the majority of patients with acute diverticulitis can be treated with medical management Outpatient treatment indicated for patients with uncomplicated diverticulitis and no signs of high fever, significant leukocytosis, peritoneal signs, sepsis, immunosuppression, advanced age, intolerance of oral intake, or significant comorbidities oral antibiotics for 7-10 days with following 2-3 days after first visit Inpatient medical management IV antibiotics with transition to oral antibiotics with improvement IV fluids Parenteral pain medications NPO if unable to tolerate oral intake Surgery indicated for patients with perforated diverticulitis, hemodynamic instability, or peritonitis can be offered electively to patients with recurrent or chronic symptoms, patients who are immunosuppressed or with a prior episode of complicated diverticulitis Complications Abscess should be suspected in patients with uncomplicated diverticulitis showing no improvement despite 3 days of antibiotic treatment if < 3cm, then treat with IV antibiotics if > 3cm, consider CT-guided percutaneous drainge Bowel obstruction Diverticular fistula Perforation Peritonitis Shock
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.GI.51) A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below. Hemoglobin: 10 g/dLHematocrit: 30%Leukocyte count: 3,500/mm^3 with normal differentialPlatelet count: 157,000/mm^3Which of the following is the most appropriate next step in management? Review Topic QID: 102680 Type & Select Correct Answer 1 Ceftriaxone and metronidazole 0% (0/3) 2 Ciprofloxacin and metronidazole 0% (0/3) 3 Colonoscopy 0% (0/3) 4 CT abdomen 100% (3/3) 5 MRI abdomen 0% (0/3) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.73) A 71-year-old female presents to her primary care physician with a four-day history of left lower quadrant abdominal pain. The patient also complains of diarrhea and mild nausea. She continues to tolerate a diet, though reduced in quantity. On exam, her vitals are T 37.7, C HR 86, BP 130/92, RR 15, and SaO2 100%. Abdominal exam is notable for left lower quadrant tenderness to palpation without rebound or guarding. Urine dipstick is normal and complete blood count shows a minor leukocytosis with a left shift. A screening colonoscopy from a year ago is shown in Figure A. What is the next best step in management? Review Topic QID: 106561 FIGURES: A Type & Select Correct Answer 1 Immediate colonoscopy 0% (0/2) 2 Trimethoprim-sulfamethoxazole and a liquid diet 100% (2/2) 3 Abdominal CT with IV contrast 0% (0/2) 4 CT angioplasty of mesenteric vessels 0% (0/2) 5 Laparotomy and surgical management 0% (0/2) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 2 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M2.GI.4672) A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease? Review Topic QID: 107190 Type & Select Correct Answer 1 Abdominal x-ray 0% (0/0) 2 Lipase 0% (0/0) 3 Abdominal CT 0% (0/0) 4 Left lower quadrant ultrasound 0% (0/0) 5 Emergent colonoscopy 0% (0/0) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M3.GI.47) A 65-year-old with a history of constipation is admitted to your floor with left lower quadrant pain. The patient states that he has been previously admitted with similar pain. He denies any medical history, but states that he does not like to eat vegetables. His wife states that he has had increasing pain over the last few days and that this time, the pain is more intense and that the patient has had higher fevers of up to 102 degrees. On exam, the patient's vitals are HR 102, T 101.9, BP 140/60, RR 14. The patient has tenderness to palpation along with rebounding and guarding. Figure A shows an axial view of CT scan of the patient's abdomen pelvis. What is the next best step for this patient? Review Topic QID: 103338 FIGURES: A Type & Select Correct Answer 1 Antibiotics and surveillance 50% (1/2) 2 Discharge home 0% (0/2) 3 Emergent operative treatment 0% (0/2) 4 Percutaneous drainage 50% (1/2) 5 Fluids 0% (0/2) M2 Select Answer to see Preferred Response SUBMIT RESPONSE 3