Topic
Review Topic
0
0
Questions
9
0
0
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
 

Please rate topic.

Average 5.0 of 2 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (9)
Lab Values
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/L
Female: 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/mL
Female: 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/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative 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/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 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/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 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/min
Female: 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 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 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

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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/dL
Hematocrit: 30%
Leukocyte count: 3,500/mm^3 with normal differential
Platelet count: 157,000/mm^3

Which of the following is the most appropriate next step in management?
Review Topic

QID: 102680
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
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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:
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.

(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
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.

(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:
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
Topic COMMENTS (2)
Private Note