Diverticular Disease

Diverticulosis refers to the presence of diverticula, or herniations of the intestinal mucosa and submucosa, most often in the sigmoid colon (Figs. 38-28 and 38-29). More than one half of patients over age 50 have incidental colonic diver-ticula. Diverticulitis is the most common complication of diverticulosis, occurring in up to 20% of patients, and results from a microperforation of a diverticulum from inspissated fecal material that often becomes a phlegmon, or a pericolic or intra-abdominal abscess.

The initial assessment of the patient with suspected divertic-ulitis should include a thorough history and physical examination, including abdominal, rectal, and pelvic examinations.

The majority of patients will have LLQ pain (93%-100%), fever (57%-100%), and leukocytosis (69%-83%). Other associated features include nausea, vomiting, constipation, diarrhea, dysuria, and urinary frequency. The differential diagnosis includes IBS, IBD, colon cancer, ischemic colitis, bowel obstruction, and gynecologic and urologic disorders (ASCRS, 2000). Initial evaluation of the patient with abdominal pain and suspected diverticulitis includes CBC, urinalysis, and flat and upright abdominal radiographs.

The American Society of Colon and Rectal Surgeons Standards Task Force for the treatment of diverticulitis state that if the patient's clinical picture clearly suggests acute diverticulitis, the diagnosis can be made on the basis of clinical criteria alone (ASCRS, 2000). The need for additional tests in the patient with suspected diverticulitis is determined by the severity of the presenting signs and symptoms and diagnostic confidence. When the diagnosis of diverticulitis is in question, other tests may include water-soluble contrast enema, abdominal CT, or ultrasonography.

Criteria for the diagnosis of diverticulitis on water-soluble contrast enema include the presence of diverticula (Figs. 38-30 and 38-31), mass effect, intramural mass, sinus tract, and extravasation of contrast. Ultrasound may reveal bowel wall thickening, abscess, and rigid hyperechogenicity of the colon caused by inflammation and may be helpful in female

Table 38-4 Causes of Massive Acute Rectal Bleeding

Cause

Frequency (%)

Upper GI Tract

Peptic ulcer disease

40-79

Gastritis, duodenitis

5-30

Esophageal varices

6-21

Mallory-Weiss tear

3-15

Esophagitis

2-8

Gastric cancer

2-3

Dieulafoy's lesion

<1

Gastric arteriovenous malformations

<1

Portal gastropathy

<1

Lower GI tract

Small Bowel

Angiodysplasia

70-80

Jejunoileal diverticula

<1

Meckel's diverticulum

<1

Neoplasms/lymphomas (benign and malignant)

<1

Enteritis, Crohn's disease

<1

Aortoduodenal fistula in patient with synthetic vascular graft

<1

Large Bowel

Diverticular disease

17-40

Arteriovenous malformations

2-30

Colitis

9-21

Colonic neoplasms, postpolypectomy bleeding

11-14

Anorectal causes (hemorrhoids, rectal varices, fissures)

4-10

Colonic tuberculosis

<1

Modified from Manning-Dimmitt LL, Dimmitt SG, Wilson GR. Diagnosis of gastrointestinal bleeding in adults. Am Fam Physician 2005;71:1339-1346.

patients to exclude pelvic or gynecologic pathology. CT with oral and IV contrast is increasingly used as the initial imaging test for patients with suspected diverticulitis, particularly if disease of moderate severity or abscess is anticipated. Endoscopy is usually avoided in the setting of acute diverticulitis because of the risk of perforating the inflamed colon, either with the instrument itself or by insufflation of air. When the diagnosis of acute colonic diverticulitis is uncertain, limited flexible sigmoidoscopy with minimum insufflation of air may be performed to exclude other diagnoses.

Conservative medical management of uncomplicated diverticulitis without associated abscess, fistula, obstruction,

Figure 38-28 Diverticulosis. (Courtesy Dr. Erik-Jan Wamsteker.)
Figure 38-29 Diverticulosis. (CourtesyDr. Erik-Jan Wamsteker.)

or perforation includes bowel rest and IV fluoroquinolones or extended-spectrum penicillins. If the patient does not improve after several days, an abscess should be suspected and diagnostic imaging considered. Conservative treatment results in resolution in 70% to 100% of cases (ASCRS, 2000). After recovery from an initial episode of diverticulitis, when the inflammation has subsided, the patient should be reevaluated. Appropriate examinations include a combination of flexible sigmoidoscopy and single-contrast or double-contrast barium enema or colonoscopy. Eventual resumption of a high-fiber diet is recommended after acute inflammation resolves; long-term fiber supplementation after the first

Figure 38-30 Sigmoid diverticula. (Courtesy Dr. PerryPernicano.)

Figure 38-31 Diverticula. (Courtesy Dr. Perry Pernicano.)

uncomplicated diverticulitis and may also be performed for patients with localized pericolic or pelvic abscess. A singlestage procedure is associated with decreased hospital stay and has lower mortality and morbidity compared with two-stage and three-stage procedures. The most common two-stage operation is Hartmann's procedure, which carries a mortality range of 2.6% to 36.8% (ASCRS, 2000). Surgical treatment of diverticulitis, in both acute and chronic settings, has been successfully accomplished by laparoscopic and laparoscopic-assisted means.

Treatment of the patient with multiple attacks of diver-ticulitis or recurrent diverticulitis is individualized to minimize the morbidity and mortality of intervention. Factors considered when deciding whether to proceed with resection include patient's age; number, severity, and interval of attacks; rapidity and degree of response to medical therapy; and persistence of symptoms after an acute attack. The risk of recurrent symptoms after an attack of diverticulitis ranges from 7% to 45%. With each episode, the patient is less likely to respond to medical therapy (70% respond to medical therapy after first attack vs. 6% after third). Thus, after two attacks of uncomplicated diverticulitis, resection is usually recommended (ASCRS, 2000).

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