Kimberly M. TreierPharmD Candidate 2016

DIVERTICULOSIS AND DIVERTICULITIS

Diverticulum – sac-like protrusion of colonic wall

Diverticulosis – presence of diverticulum Symptomatic or asymptomatic

Diverticular disease – symptomatic diverticulosis due to diverticular bleeding, diverticulitis, segmental colitis associated with diverticula (SCAD) or symptomatic uncomplicated diverticular disease (SUDD)

Diverticulitis – inflammation of diverticulum Acute or chronic Complicated diverticulitis – diverticulitis with one of the following:

bowel obstruction, abscess, fistula or perforation Uncomplicated diverticulitis – diverticulitis without associated

complication

DEFINITIONS

BACKGROUND

BACKGROUND

Diverticulosis DiverticulitisSUDDAbdominal pain- Nonspecific- Constant or relieved by

flatulation/defecationBloating and change in bowel habits

Diverticular bleedPainless hematochezia- Typical presentation- Usually self-limitingAbdominal symptoms- Usually few due to non-inflammatory

process- Bloating, cramping, urge to defecateSyncope, lightheadedness, postural dizziness- With severe bleed

SCADChronic diarrheaCramping abdominal pain- Primarily left lower quadrant- Intermittent hematochezia

Abdominal pain - Usually left lower quadrant (sigmoid

colon)- Constant- Present for several daysNausea and vomiting- Bowel obstruction- Peritoneal irritationLow-grade feverHemodynamic instability/shock- Perforation - PeritonitisTender mass- Inflammation or peridiverticular abscessAbdominal guarding, rigidity, rebound tendernessStool positive for occult bloodChange in bowel habits- Constipation (~50%)- Diarrhea (~25-30%)Urinary urgency, frequency, dysuria, fecaluria- Bladder irritation- Fistula

PRESENTATION

Diverticulosis DiverticulitisSUDDHistoryPhysical exam- Fullness/tenderness in left lower

quadrant- Tender palpable loop of sigmoid colonColonoscopy

Diverticular bleedPhysical exam- Normotensive (usually)- Normal abdominal exam, may have

some tenderness to palpation- Blood per rectal examLabs- Hgb: normal (<24h) or low (>24h) - RBCs: normocytic (acute bleed) or

microcytic (chronic bleed) - BUN:SCr or urea:SCr: normal (vs. upper

GI bleed)ColonoscopyRadiographology

HistoryPhysical exam- Lower abdominal pain and tenderness- Pelvic exam (women) to r/o other causesLabs- CBC (often see leukocytosis)- Electrolytes- R/o UA- R/o pregnancy test (women)Labs – suspected perforation and diffuse peritonitis- Serum aminotransferases- Alkaline phosphatase- Bilirubin- Amylase- LipaseCultures – only patients with diarrhea- R/o infectious processImaging- CT scan- Ultrasound

DIAGNOSIS

Diverticulosis DiverticulitisSCADEndoscopy- Inflammation of interdiverticular mucosa- Reddish lesions, ulcers, edema, diffuse

erosionsHistology- Chronic inflammatory changes

(inflammatory infiltration, glandular architecture changes, crypt abscess, crypt hemorrhage)

HistoryPhysical exam- Lower abdominal pain and tenderness- Pelvic exam (women) to r/o other causesLabs- CBC (often see leukocytosis)- Electrolytes- R/o UA- R/o pregnancy test (women)Labs – suspected perforation and diffuse peritonitis- Serum aminotransferases- Alkaline phosphatase- Bilirubin- Amylase- LipaseCultures – only patients with diarrhea- R/o infectious processImaging- CT scan- Ultrasound

DIAGNOSIS

Diverticulosis DiverticulitisDiverticular bleedMassive upper GI bleedColon cancerIBDUlcersAngiodysplasiaSevere hemorrhoidal bleeding

SCADAcute uncomplicated diverticulitisIBDMedication-associated colitisInfectious colitisSolitary rectal ulcer syndromeRadiation colitis

Colorectal cancerAcute appendicitisIBDInfectious colitisIschemic colitis

Other- Tubo-ovarian abscess- Ovarian cyst- Ovarian torsion- Ectopic pregnancy- Cystitis- nephrolithiasis

DIFFERENTIAL DIAGNOSIS

Diverticulosis DiverticulitisSUDDDietary modifications- Clear liquids- High fiberAntibiotic- Broad-spectrum (gram(-) and anaerobes)SpasmolyticsAnticholinergics

Diverticular bleedResuscitation- Fluids- Blood productsEndoscopic therapy- Epinephrine injection- Endoscopic tamponade- BandingAngiographic therapy- Pharmacologic occlusion- Mechanical occlusionSurgery

Dietary modifications- Clear liquids- High fiber- Bowel rest (inpatient, severe cases)Antibiotic therapy- May not be necessary- Target gram (-) rods and anaerobes - 7-14 days based on symptoms- Outpatient: ciprofloxacin 500 mg PO BID + metronidazole 500 mg PO TID OR amox-clav 875/125 mg BID- Inpatient: ceftolazone 1 g + tazobactam 0.5 g + metronidazole 500 mg IV every 8 hoursAnti-inflammatory agents- Mesalamine Drainage- AbscessSurgery

TREATMENT

Diverticulosis DiverticulitisSCADDietary modifications- Clear liquids- High fiber

Antibiotic therapy1. Ciprofloxacin 500 mg BID +

metronidazole 10 mg/kg daily x 10-14 days

2. Mesalamine 800 mg TID x 7-10 days3. Mesalamine 1600 mg TID4. Prednisone 40 mg daily x 7 days, then

taper over 6 weeks5. Recurrent symptoms: long-term

ciprofloxacin6. Steroid-refractory/dependent: segmental

resection

AsymptomaticHigh fiberLow-fatPhysical activity

Dietary modifications- Clear liquids- High fiber- Bowel rest (inpatient, severe cases)Antibiotic therapy- May not be necessary- Target gram (-) rods and anaerobes - 7-14 days based on symptoms- Outpatient: ciprofloxacin 500 mg PO BID + metronidazole 500 mg PO TID OR amox-clav 875/125 mg BID- Inpatient: ceftolazone 1 g + tazobactam 0.5 g + metronidazole 500 mg IV every 8 hoursAnti-inflammatory agents- Mesalamine Drainage- AbscessSurgery

TREATMENT

Pemberton JH, Young-Fadok T. Colonic divert iculosis and divert icular disease: Epidemiology, r isk factors, and pathogenesis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 Apri l 2016).

Tursi A. Divert icular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. 2010 Feb 6;1(1):27-35. doi:10.4292/wjgpt.v1. i1.27

Salzman, H, Li l l ie D. Diverticular Disease: Diagnosis and Treatment. Am Fam Physician. 2005 Oct 1;72(7):1229-1234

Young-Fadok T, Pemberton JH. Colonic diverticular bleeding. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 Apri l 2016.)

Young-Fadok T, Pemberton JH. Segmental col i t is associated with diverticulosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 Apri l 2016.)

Pemberton JH, Young-Fadok T. Cl inical manifestations and diagnosis of acute diverticul i t is in adults. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 Apri l 2016.)

Pemberton JH, Young-Fadok T. Nonoperative management of acute uncomplicated diverticul i t is . In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 Apri l 2016.)

REFERENCES