|
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 
 

Please rate topic.

Average 4.5 of 2 Ratings

Questions (8)
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

(M2.GI.49) An 82-year-old male with a medical history significant for arthritis, glaucoma, and cardiac pacemaker presents with a 3-day history of lower abdominal pain. His medications include a baby aspirin and pilocarpine. Vitals include a temperature of 101 degrees F, blood pressure of 150/80, and pulse of 95/min. On exam, the patient has extreme left lower quadrant abdominal tenderness. A CT scan shows perisigmoid stranding and sigmoid diverticula. Antibiotics are administered. Two days later, the patient returns due to persistent left-lower quadrant abdominal pain. A CT scan now reveals a 4-cm perisigmoid fluid collection. What is the most appropriate next step in management? Review Topic

QID: 106333
1

Continue oral antibiotics and observe

5%

(2/44)

2

Switch to broader spectrum antibiotics and observe

0%

(0/44)

3

Percutaneous drainage of fluid collection under CT guidance

61%

(27/44)

4

Laparotomy for drainage and debridement

18%

(8/44)

5

Laparotomy with sigmoid resection

11%

(5/44)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M3.GI.59) A 62-year-old male is evaluated in the emergency department for an episode of painless bright red blood per rectum for 2 hours. The patient is known to have sigmoid diverticulosis, noted on colonoscopy 1 month ago. The patient's bleed most likely arose from a distal branch of which of the following vessels? Review Topic

QID: 102688
1

Superior mesenteric vein

0%

(0/1)

2

Super mesenteric artery

100%

(1/1)

3

Inferior mesenteric vein

0%

(0/1)

4

Inferior mesenteric artery

0%

(0/1)

5

Superior hemorrhoidal artery

0%

(0/1)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M3.GI.51) A 68-year-old male presents to the emergency department with left lower quadrant pain and fever for 1 day.

Laboratory results show:
WBC 14.8 cells/mm^3
Hb 12.0 g/dL
Hct 38%

Na 138 mEq/L
K 4.0 mEq/L
Creatinine 1.0 mg/dL

Which of the following studies is contraindicated in the workup of this patient? Review Topic

QID: 102680
1

MRI

0%

(0/3)

2

Ultrasound

0%

(0/3)

3

Contrast CT

0%

(0/3)

4

Colonoscopy

100%

(3/3)

5

Abdominal radiograph

0%

(0/3)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.GI.30) A 69-year-old male presents with severe left-lower quadrant (LLQ) pain. Vitals are remarkable for a temperature of 38.3 C. Labs are remarkable for a WBC count of 15,000. An abdominal CT scan shows a localized abscess of 2.5 cm near an inflamed diverticulum. What is the next step in the management of this patient? Review Topic

QID: 106103
1

Oral antibiotics

0%

(0/6)

2

IV antibiotics

67%

(4/6)

3

CT-guided percutaneous drainage

33%

(2/6)

4

Laparotomy

0%

(0/6)

5

NPO, IV fluids, and observation

0%

(0/6)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
EVIDENCE & REFERENCES (12)
Topic COMMENTS (4)
Private Note