Diverticulosis

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    • Divericular disease
      • Herniation of the mucosa and submucosa through the muscular layers of the bowel wall at sites where arterioles penetrate, forming small out- pouchings or diverticula. (MCQ)
      • Diverticula occur on the mesenteric side of the colon. . (MCQ)
      • > 50% over 70 years of age . (MCQ)
      • Men and women equally affected
      • Sigmoid colon most commonly involved with progressively decreasing frequency of involvement as one proceeds proximally. (MCQ)
      • Risk factors. (MCQ)
        • Old age
        • Low-fiber diet
      • Signs and symptoms
        • Diverticulosis
          • 80% of patients asymptomatic.
          • May cause recurrent, intermittent left lower quadrant (LLQ) pain and tenderness that often follows a meal and is relieved by flatus or defecation. . (MCQ)
          • LLQ rope-like mass sometimes palpable on exam. . (MCQ)
          • Massive lower GI bleeding is classic (notably absent in diverticulitis). . (MCQ)
        • Diverticulitis
          • Persistent abdominal pain initially diffuse in nature that often becomes localized to the LLQ with development of peritoneal signs . (MCQ)
          • LLQ and/or pelvic tenderness
          • Ileus
          • Fever, anorexia, nausea, vomiting,
          • change in bowel habits (usually constipation) (MCQ)
          • Elevated WBC
      • Diagnosis
        • Diverticulosis
          • Characteristic history and physical exam confirmed by diverticula iden- tified on barium enema and/or colonoscopy.
        • Diverticulitis
          • Characteristic history and physical exam with elevated WBCs
          • Abdominal x-ray: Ileus, distention, and/or free intraperitoneal air(MCQ)
          • CT scan:
            • Pericolonic inflammation with or without abscess formation (MCQ)
            • barium enema and colonoscopy may induce perforation and are contraindicated in the acute setting but should be obtained in follow-up(MCQ)
      • Treatment
        • Diverticulosis:
          • High-fiber diet, stool softeners. (MCQ)
        • Mild diverticulitis:
          • Outpatient management:
            • Clear liquid diet, PO antibiotics(MCQ)
            • non-opioid analgesics with close follow-up.
            • Follow-up includes colonoscopy and dietary recommendations once acute infection has subsided.
          • If outpatient therapy fails, admit for IV antibiotics and IV hydration with bowel rest.
          • Nasogastric tube (NGT) is placed when there is evi- dence of ileus or small bowel obstruction (SBO), with nausea and vom- iting. (MCQ)
        • Severe diverticulitis with peritonitis and/or perforation:
          • Two-stage procedure with initial surgical drainage and diverting colostomy followed by colonic reanastomosis 2 to 3 months later. (MCQ)
          • Elective resection of affected bowel may be considered in the patient who has recurrent episodes of diverticulitis requiring treatment. (MCQ)
      • Prognosis
        • Seventy percent of patients have no recurrence after one episode of un- complicated diverticulitis.
        • After a second episode, 50% recur.
      • Clinical Pearls :
        • Recommend colonscopy (MCQ)
          • after 7 years of pancolitis
          • after 10 years of left-sided colitis
          • then scope and biopsy every 1 to 2 years
        • The diverticula of common diverticulosis are false diverticula, because only the mucosa and submucosa herniated rather than all the layers of the bowel wall. (MCQ)
        • Pathology of diverticulitis:
          • A peridiverticular inflammation caused by (usually tiny) perforation of the diverticulum secondary to increased pressure or obstruction by inspissated feces.
          • Feces extravasate onto the serosal surface but infection is usually well contained in a patient with normal immune function.


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