Updated: 10/22/2019

Diverticular Disease

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Snapshot
  • A 65-year-old man with a long history of constipation presents with bright red blood per rectum for 1 day. He denies any straining, abdominal pain, diarrhea, or lightheadedness. He denies any recent trauma and family history is unremarkable. His last colonoscopy was about 12 years ago and patient reports he had some "blebs" in his colon. Physical exam was largely unremarkable and a rectal exam did not show any perianal fissures or hemorrhoids. Stool hemocult test is positive. (Diverticulitis) 
Introduction
  • Overview 
    • diverticulosis
      • condition of having multiple sac-like protrusions (diverticula) of the colonic wall that are not inflamed
      • the diverticula are outpouchings of the colonic mucosa and submucosa through areas of weakness within the muscle layers of the colon wall
    • diverticulitis 
      • is defined as inflammation of a diverticulum
      • results from a microscopic or macroscopic perforation of a diverticulum due to diverticular inflammation and focal necrosis
      • patients can present with repeated attacks
  • Epidemiology
    • demographics
      • prevalence increases with age with a prevalence of 60% by age 60
      • location of the diverticula varies by geography
        • sigmoid colon is the most common location in Western countries
        • predominately at the right-side in Asian countries
    • risk factors
      • age
      • low dietary fiber
      • high fat and red meat intake
      • physical inactivity
      • obesity
      • smoking
      • positive family history
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Pathogenesis
    • diverticulosis
      • abnormal colonic motility leading to the colonic mucosa and submucosa to herniate through well-defined points of weakness at the muscle layer 
        • points of weakness correspond to where the vasa recta penetrate the circular muscle layer of the colon
        • a typical colonic diverticulum is a “false diverticulum” and is only covered by serosa
    • diverticulitis
      • 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
  • Associated conditions 
    • collagen disorders 
      • e.g., Marfan and Ehlers-Danlos 
    • ADPKD
Presentation
  • Diverticulosis
    • symptoms
      • asymptomatic
      • cramping
      • bloating
      • flatulence
      • irregular defecation
      • painless rectal bleeding
    • physical exam
      • left lower quadrant (LLQ) pain and tenderness
  • Diverticulitis
    • 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) 
Imaging
  • Colonoscopy 
    • gold standard
    • allows for visualization of diverticula and rule out of differential (e.g., malignancy)
    • not recommended during an acute diverticulitis attack
      • recommended 4-6 weeks after resolution for evaluation and rule out of malignancy
  • Computed tomography (CT) with contrast 
    • best for evaluation of acute diverticulitis
    • 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
  • Plain abdominal radiograph
    • may show signs of constipation
    • rules out other causes of abdominal pain (e.g., small bowel obstruction)
    • may be useful in detecting pneumoperitoneum and obstruction
    • positive findings include air-fluid levels with bowel dilation or free air
Studies 
  • CBC and iron studies for evaluation of anemia secondary to blood loss
    • may see leukocytosis in diverticulitis 
  • 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
  • Colon/rectal cancer
    • differentiating factors
      • may complain of symptoms (e.g., stool changes) and lesion will be present on colonoscopy
  • Acute appendicitis
    • differentiating factors
      • will appear differently on abdominal CT imaging
Treatment
  • Diverticulosis
    • lifestyle changes 
      • high-fiber diet to prevent constipation
    • in the case of diverticular bleeding
      • resuscitation (e.g., IV fluids and blood products)
      • colonoscopy with cauterization
      • if bleeding is not identified with colonoscopy, then angiography is indicated
      • surgery is the last resort if the bleeding cannot be controlled with colonoscopy or angiography
  • Diverticulitis
    • 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
  • Anemia
  • Bleeding/hemorrhage
  • Exsanguination
  • Abscess
    • should be suspected in patients with uncomplicated diverticulitis showing no improvement despite 3 days of antibiotic treatment
  • Bowel obstruction
  • Diverticular fistula
  • Perforation
  • Peritonitis
  • Shock
 

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Questions (1)
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
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