Diverticular Disease (Diverticulosis, Diverticulitis)

BASIC INFORMATION

ICD-10CM CODES
K57.30Diverticulosis of large intestine
without perforation or abscess
without bleeding
K57.32Diverticulitis of large intestine
without perforation or abscess
without bleeding
K57.31Diverticulosis of large intestine
without perforation or abscess with
bleeding

EPIDEMIOLOGY &
DEMOGRAPHICS


Incidence of diverticulosis in the general
population is 35% to 50%. Prevalence of
diverticulosis increases with ages (<10%
under age 40 to 80% in those >85).
Diverticulosis is more common in Western
countries, affecting >30% of people >40 yr
and >50% of people >70 yr.
Approximately 20% of patients with diverticula have an episode of diverticulitis.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Physical examination in patients with diverticulosis is generally normal.
Painful diverticular disease can present with
left lower quadrant (LLQ) pain, often relieved
by defecation; location of pain may be anywhere in the lower abdomen because of the
redundancy of the sigmoid colon.


Diverticulitis can cause muscle spasm,
guarding, and rebound tenderness predominantly affecting the LLQ.
ETIOLOGY
Diverticular disease is believed to be secondary to low intake of dietary fiber.
Recent studies indicate a pathogenetic role
for inflammation in diverticulitis that may be
similar to that of IBS, IBD, or both, based on
common histologic findings such as granulomas, infiltrating lymphocytes, TNF, histamine,
and matrix metalloproteinases.1

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Irritable bowel syndrome
1Morris

AM etal: Sigmoid diverticulitis: a systematic

review, JAMA 311(3):287-297, 2014.

colitis,

LABORATORY TESTS
WBC count in diverticulitis reveals leukocytosis with left shift.
Microcytic anemia can be present in patients
with chronic bleeding from diverticular disease. MCV may be elevated in acute bleeding
secondary to reticulocytosis.
PROCEDURES: Colonoscopy should be avoided
during acute diverticulitis due to the risk of
perforation. It can generally be performed
after 6 wk to rule out the presence of cancer
and IBD.
IMAGING STUDIES
If clinical features are highly suggestive of
diverticulitis, imaging studies are generally
not necessary.
A CT scan of the abdomen (Fig. 1D-39) is
the preferred radiologic examination to diagnose acute diverticulitis. It can also diagnose
diverticulosis. It has a sensitivity of 93% to
97% and a specificity approaching 100%
for diverticulitis. Typical findings are thickening of the bowel wall, fistulas, or abscess
formation. CT may also reveal other disease
processes (e.g., appendicitis, tubo-ovarian
abscess, Crohns disease) accounting for
lower abdominal pain
Evaluation of suspected diverticular bleeding:
1. 
Arteriography if the bleeding is faster
than 1 ml/min (advantage: the possible
infusion of vasopressin directly into the
arteries supplying the bleeding, as well as
selective arterial embolization; disadvantages: its cost and invasive nature)
2. Technetium-99m sulfa colloid
3. Technetium-99m labeled RBC (can detect
bleeding rates as low as 0.12 to 5 ml/min)

TREATMENT

colonic flora and metronidazole 500 mg q6h

for anaerobes) and liquid diet for 7 to 10
days are commonly prescribed. However,
randomized trials and cohort studies have
shown that antibiotics are not as beneficial
as previously thought and that mesalamine
might be useful.
Severe case: NPO and aggressive IV antibiotic therapy
a. Ampicillin-sulbactam 3 g IV q6h or
b. Piperacillin-tazobactam 4.5 g IV q8h or
c. Ciprofloxacin 400 mg IV q12h plus metronidazole 500 mg IV q6h or
d. Ticarcillin-clavulanate 3.1 g IV q6h
Life-threatening case: imipenem 500 mg IV
q6h or meropenem 1 g IV q8h


Surgical treatment (laparoscopic preferred
over open colectomy) consisting of resection of involved areas and reanastomosis (if
feasible); otherwise a diverting colostomy
with reanastomosis performed when infection has been controlled; surgery should be
considered in patients with:
1. Repeated episodes of diverticulitis (two or
more)
2. 
Poor response to appropriate medical
therapy (failure of conservative management)
3. Abscess or fistula formation
4. Obstruction
5. Peritonitis
6. Immunocompromised patients, first episode in young patient (<40 yr old)
7. 
Inability to exclude carcinoma (10% to
20% of patients diagnosed with diverticulosis on clinical grounds are subsequently
found to have carcinoma of the colon)
DIVERTICULAR HEMORRHAGE:
1. Bleeding is painless and stops spontaneously
in the majority of patients (60%); it is usually caused by erosion of a blood vessel by a
fecalith present within the diverticular sac.
2. Medical therapy consists of blood replacement and correction of volume and any clotting abnormalities.

3. 
Colonoscopic treatment with epinephrine
injections, bipolar coagulation, or both may
prevent recurrent bleeding and decrease the
need for surgery.

NONPHARMACOLOGIC THERAPY
Increase in dietary fiber intake and regular
exercise to improve bowel function. However,
recent studies have challenged the common
view that fiber intake protects against diverticulosis
NPO and IV hydration in severe diverticulitis;
NG suction if ileus or small bowel obstruction
is present
Emergent surgery is required for perforation,
peritonitis, or uncontrolled sepsis.
ACUTE GENERAL Rx
TREATMENT OF DIVERTICULITIS:


Mild case: broad-spectrum PO antibiotics
(e.g., ciprofloxacin 750 mg bid or levofloxacin
750 mg bid or trimethoprim/sulfamethoxazole DS bid to cover aerobic component of

FIGURE 1D-38 Colonoscopic appearance of

diverticular disease affecting the sigmoid
colon. (From Forbes A etal: Atlas of clinical gastroenterology, ed 3, Edinburgh, 2005, Elsevier.)

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Diseases
and Disorders

DEFINITION
Colonic diverticula are herniations of mucosa
and submucosa through the muscularis (Fig.
1D-38). They are generally found along the
colons mesenteric border at the site where
the vasa recta penetrates the muscle wall
(anatomic weak point).
Diverticulosis is the asymptomatic presence
of multiple colonic diverticula.
Diverticulitis is an inflammatory process or
localized perforation of diverticulum.

IBD
Carcinoma of colon
Endometriosis
Ischemic colitis


Infections (pseudomembranous
appendicitis, pyelonephritis, PID)
Lactose intolerance
Celiac disease

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Diverticular Disease (Diverticulosis, Diverticulitis)

DISPOSITION


The risk of recurrence among patients
with uncomplicated diverticulitis is 32%
to 36%. Most patients with diverticulitis
respond well to antibiotic management
and bowel rest. Up to 30% of patients with
diverticulitis will eventually require surgical management.
Diverticular bleeding can recur in 15% to
20% of patients within 5 yr.
REFERRAL
GI referral for colonoscopy 4-6 wk after resolution of symptoms. In patients who have
complications from diverticulitis, colonoscopy
is not necessary after radiologically proven
uncomplicated diverticulitis. Surgical referral
when considering resection.
FIGURE 1D-39 Sigmoid diverticulitis. Enhanced CT shows haziness associated with extraluminal air in the
sigmoid mesocolon due to perforated diverticulitis, also manifested as a thickened sigmoid wall. Thickening at
the root of the sigmoid mesocolon is also present (arrow). (From Grainger RG etal [eds.]: Grainger and Allisons
diagnostic radiology, ed 4, Philadelphia, 2001, Churchill Livingstone.)

4. Surgical resection is necessary if bleeding

does not stop spontaneously after administration of 4 to 5 U of PRBCs or recurs with
severity within a few days; if attempts at
localization are unsuccessful, total abdomi-

nal colectomy with ileoproctostomy may be

indicated (high incidence of rebleeding if
segmental resection is performed without
adequate localization).

SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Diverticular Disease (Patient Information)
Diverticulitis (Patient Information)
Diverticulosis (Patient Information)
AUTHOR: FRED F. FERRI, M.D.

Descargado de ClinicalKey.es desde Instituto Technologico Estudios Superiores Monterrey - Monterrey agosto 31, 2016.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

Diverticular Disease (Diverticulosis, Diverticulitis)

SUGGESTED READINGS
Jacobs DO: Diverticulitis, N Engl J Med 357:20572066, 2007.
Perry AF, etal.: A high-fiber diet does not protect against asymptomatic diverticulosis, Gastroenterology 142(266), 2012.
Wilkins T, etal.: Diagnosis and management of acute diverticulitis, Am Fam
Physician 87(9):612620, 2013.

Descargado de ClinicalKey.es desde Instituto Technologico Estudios Superiores Monterrey - Monterrey agosto 31, 2016.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.

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