Diverticulitis: Clinical sciences

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Introduction0:00–1:08

Diverticulitis is inflammation of a diverticulum, which is a small pouch protruding from the bowel wall. Be sure not to mix it up with diverticulosis, which is the presence of multiple diverticula that develop because of a high-fat and low-fiber diet.
However, even though it is commonly believed, eating things like seeds, nuts, and popcorn does not increase the risk of developing diverticulosis or diverticulitis.Now, diverticulitis occurs when increased bowel pressure, from things like food or stool, causes a tiny hole or micro perforation in the diverticulum wall.
This allows bacteria from the lumen to seed the diverticulum, which results in infection and inflammation. Diverticulitis can be classified as uncomplicated or complicated diverticulitis.
In uncomplicated diverticulitis, only the diverticulum is inflamed, while in complicated diverticulitis, perforation, abscess, or fistula might be present as well.Alright, when a patient presents with signs and symptoms of diverticulitis, you should first perform an ABCDE assessment.

Unstable1:08–1:32

The individual can be unstable if septic shock develops, so you should stabilize their airway, breathing, and circulation.
This means that you may need to intubate the patient, establish IV access, or administer fluids before continuing with your assessment.However, if the patient is stable, the next step is to obtain a focused history and physical examination.

History, physical, and labs1:32–3:35

History typically reveals abdominal pain, most often in the left lower quadrant, and sometimes symptoms like fever, nausea, vomiting, and recent changes in bowel habits, such as constipation or diarrhea.Physical examination usually reveals abdominal distention and tenderness in the affected area, most commonly in the left lower quadrant.
There can also be elevated temperature. The most dangerous signs to look for are guarding, rigidity, and rebound pain, which point to peritonitis.A rectal examination may reveal a palpable mass within the distal sigmoid colon.
The stool may also be positive for occult blood.An important thing to remember is that rectal bleeding is more commonly associated with diverticulosis than diverticulitis.
However, unlike diverticulitis, diverticulosis is usually asymptomatic and found incidentally.Alright, as for the labs, check for leukocytosis, elevated CRP, and lactate.
These are not specific for acute diverticulitis, but may support the diagnosis.In terms of imaging, order a CT scan of the abdomen and pelvis with oral and IV contrast.In uncomplicated diverticulitis, CT examination reveals diverticula which are outpouchings of the bowel wall, focal thickening of the bowel wall, and pericolonic fat stranding in the region of the inflamed diverticula.In complicated diverticulitis, you might also see an associated abscess, pneumoperitoneum, or fistula.
For example, air bubbles within the bladder might be a sign of a colovesical fistula.Okay, if the CT scan suggests uncomplicated diverticulitis, you can manage them conservatively.

Uncomplicated diverticulitis3:35–5:44

When we’re talking about uncomplicated diverticulitis, we’re referring to inflammation of diverticula without any complications such as sepsis, frank perforation, abscess, or fistula.
Uncomplicated diverticulitis can be treated non-surgically in the outpatient setting. Treatment usually includes pain management and a clear liquid diet, followed by re-evaluation in about 2-3 days to determine if there’s been any improvement.Antibiotics are not typically used in uncomplicated diverticulitis unless an individual has certain risk factors.
These include age > 70 years, comorbidities such as heart disease or diabetes mellitus, immunosuppression due to medications such as corticosteroids or chemotherapy, HIV, transplant recipients, or pregnancy.If used, antibiotics should cover gram-negative rods and anaerobes, so possible combinations include fluoroquinolones plus metronidazole, trimethoprim-sulfamethoxazole plus metronidazole, or a penicillin with a beta-lactamase inhibitor.After 2-3 days, patients should return for a re-evaluation.
If their symptoms improve, they can begin to incorporate solid foods again. Continue to re-evaluate them until their symptoms completely resolve.
Finally, they will need a colonoscopy about 6-8 weeks after the symptoms resolve to evaluate the extent of the disease and to exclude potential masses within the colon.
If their symptoms persist, they will need inpatient management. They should be NPO, and receive pain management, IV fluid, and IV antibiotics.
If they have recurrent episodes of diverticulitis, you should call a surgical consultation for possible elective resection with primary anastomosis.Now, if the CT reveals signs of complicated diverticulitis, then you should get a surgical consult and admit the patient to the hospital for inpatient management.

Complicated diverticulitis5:44–8:15

These patients should be NPO, so you’ll also need to start IV fluids. As in uncomplicated diverticulitis, you’ll want to administer treatment for pain management.
Additionally, you should start empiric antibiotics that cover gram-negative rods and anaerobes to reduce the risk of sepsis.Alright, there are several ways complicated diverticulitis can present, including frank perforation, abscess and fistula.First, frank perforation of the colon wall may allow air and stool to leak into the abdomen and cause peritonitis.
These patients require an emergent laparotomy and resection of the affected area of the colon, or partial colectomy. Then a free section of the colon is connected to the abdominal wall and this is called a colostomy.
The opening is called a stoma and it allows stool to drain into an ostomy bag. This is a temporary measure that allows the patient to stabilize and for any infection or inflammation to resolve.
After a few months, the surgeon will do an elective re-anastomosis procedure to reverse the colostomy and reconnect the two ends of the colon.The next possible CT finding of complicated diverticulitis is an abscess.
You can usually treat a small abscess, meaning it’s 3 centimeters or less, with IV antibiotics. Follow up with serial exams and labs to make sure treatment is working.
On the other hand, if the abscess is large, meaning greater than 3 centimeters, then antibiotics alone might not be enough, and percutaneous drainage will be needed if their condition worsens.
Serial exams and labs should be done, and if the condition worsens, colectomy might be required.Additionally, fistulas are a possible complication of diverticulitis.
A fistula is an abnormal connection between two adjacent organs. The most common fistulas in diverticulitis are colovesical, between the colon and bladder, and colovaginal, between the colon and the vagina.
In both cases, a surgeon will also need to perform an elective repair. In colovesical fistulas, the bladder will need to be repaired as well, while in a colovaginal fistula, the vaginal fistula may close on its own or be closed with a suture.Alright, as a quick recap…A patient with diverticulitis can present as stable or unstable.
Unstable patients should be stabilized before doing any assessments. To diagnose diverticulitis, a CT scan of the abdomen and pelvis with IV and PO contrast should be ordered.

Recap8:15–9:00

Based on the CT findings, diverticulitis can be uncomplicated or complicated. Uncomplicated diverticulitis is usually managed in the outpatient setting with pain medications and diet modifications, although oral antibiotics are used in individuals with risk factors.
On the other hand, complicated diverticulitis can be associated with frank perforation, abscess, or a fistula. Frank perforation requires immediate surgery.
Small abscesses can be treated with IV antibiotics, while larger ones require IV antibiotics and percutaneous drainage.
Diverticulitis: Video, Causes, and Symptoms | Osmosis