Kembara Xtra - Medicine - Diverticular Disease Introduction Diverticula are several or single diverticula that protrude from the colonic wall. Diverticular disease is a group of illnesses that affects the whole GI system, with the exception of the rectum: Diverticular disease with associated inflammation and/or infection is referred to as acute diverticulitis. Asymptomatic diverticulosis is a common incidental finding on routine colonoscopy or imaging. Symptomatic diverticulosis is also known as symptomatic uncomplicated diverticular disease (SUDD); recurrent abdominal pain associated with diverticulosis without colitis or diverticulitis. Diverticular bleeding makes for more than 40% of lower GI bleeds; it frequently manifests as painless hematochezia until it's accompanied by active diverticulitis. Right-sided diverticula are more prone to bleeding. Diverticular illness is responsible for around 300,000 hospital admissions each year in the US. Diverticulitis develops throughout the course of a lifetime in 1-2% of the general population and in 4% of diverticulosis patients. In 3-5% of patients with diverticulosis, bleeding from the diverticulum occurs. Diverticulosis is more common as people age, as do the number of diverticula. Diverticulosis affects 20% of people under 40, 60% of people over 60, and 70% of those over 80. Diverticulitis incidence increased from 62 to 75/100,000 between 1998 and 2005; the biggest rise was seen in patients under 45 years old and was mostly caused by dietary changes. Males and females are equally affected, with men over 65 years of age having a higher incidence than women over 65. Pathophysiology and Etiology Diverticula develop in weak spots in the intestinal wall when tiny blood vessels (vasa recta) pierce through the colon's muscular layer. Diverticulosis is caused by aging-related mucosal wall degeneration, increased intraluminal pressure from thick, fiber-deficient stools, and aberrant colonic motility. The majority of right-sided diverticula engage all layers of the intestinal wall and are real diverticula. The majority of left-sided diverticula are pseudodiverticula (only submucosal and mucosal outpouchings). Diverticulitis develops when localized infection and inflammation cause tissue necrosis with a possibility of mucosal micro- or macroperforation. Microscopy indicates cryptitis, ulceration, mucin deficiency, necrosis, and inflammation with lymphocytic infiltration. Intestinal microbiota changes are a factor in chronic inflammation. Diverticular illness and irritable bowel syndrome may be on the same disease continuum; bleeding susceptibility is increased by vasa recta thinned over the diverticula's neck. Although there is no hereditary pattern for diverticular disease, heredity may have a role. Asian and African people have lower overall prevalence but develop the condition when they adopt a Western lifestyle. Risk Elements Age over 40; a low-fiber diet; a sedentary lifestyle; obesity; and a history of diverticulitis. The risk increases when there are more diverticula. Smoking increases the risk of perforation; NSAIDs, steroids, and opiate analgesics increase the risk of diverticular hemorrhage. Statins and calcium channel blockers stop diverticular hemorrhage. Preventive measures include a high-fiber diet or non-absorbable fiber (like psyllium) and regular exercise. Accompanying Conditions Obesity, inflammatory bowel disease, connective tissue diseases, colon cancer, and irritable bowel syndrome Diverticulosis patients make up 80–85% of the population with no symptoms. 1-2% of those 15-20% with symptoms will need to be hospitalized, and 0.5% will need surgery. – The most typical symptom is a colicky, dull abdomen ache that usually occurs in the LLQ. Eating and having a bowel movement or flatus can both make pain worse. – Constipation or diarrhea are frequent. Uncomplicated (85%) and complex (15%) cases of acute diverticulitis - Fever and/or chills: abrupt onset, usually in LLQ, abdominal pain - Anorexia, vomiting, or nausea (20-62%). - Diarrhea (25–35%) or constipation (50%) - Dysuria and frequent urination point to ureteral or bladder discomfort. - Pneumaturia and fecaluria if a colovesical fistula is present. Hematochezia, Melena, and diverticular hemorrhage (0.5/1,000 person-years) - No pain during rectal bleeding Immunocompromised patients are more likely to develop perforation and abscesses and may not exhibit fever or leukocytosis. clinical assessment Diverticulosis: The exam is typically unremarkable. - Intermittent tympany or distension may occur. - Stools + heme possible Acute diverticulitis - pain in the abdomen (often LLQ) - Distension and tympany in the abdomen - Rebound pain, involuntary guarding, or rigidity suggest perforation and/or peritonitis. - 20% palpable bulk in LLQ - Hypoactive bowel noises, which, if an obstruction is present, may be high-pitched and intermittent. - A rectal exam may indicate a lump or areas of tenderness. Fistulas in the perirectal, colovesical, and vaginal areas rarely occur initially. Multiple Diagnoses Nephrolithiasis, irritable bowel syndrome, lactose intolerance, cancer, inflammatory bowel disease, fecal impaction, bowel blockage, angiodysplasia, ischemic colitis, acute appendicitis, and ectopic pregnancy are all examples of conditions that can affect the urinary system. Laboratory Results Initial examinations (lab, imaging) Diverticulosis: no lab work or imaging are required; acute diverticulitis: up to 45% of individuals have a normal WBC count. With a left shift, the WBC count rises as the diverticulitis gets worse. - Normal hemoglobin level (barring hemorrhage) - Elevated ESR - Microscopic pyuria or hematuria may be visible in urine analysis. - Urine culture is often benign, but a recurrent infection raises the possibility of a colovesical fistula. - Positive blood cultures in systemic illnesses - Plain abdominal films (acute abdominal series—supine and upright) to check for bowel obstruction (dilated loops of intestine) and open air under the diaphragm (bowel perforation). - CT scan to stage the disease and select the best course of action (sensitivity: 98%, specificity: 99%).- Useful options include ultrasound and MRI (sensitivity: 94%, specificity: 92%). - Because of the possibility of peritoneal extravasation, barium enema is not advised. Diverticular bleeding, bleeding anemia, and coagulopathy should all be investigated. Diverticular bleeding and other diagnostic procedures Endoscopy to assess GI bleeding; NG lavage to rule out upper GI bleeding; and angiography if bleeding prevents endoscopy from being performed or when endoscopy is unable to identify the source A follow-up angiography to localize bleeding after a 99mTc-pertechnetate-labeled RBC scan (more sensitive), which was not examined in a comparison experiment. Management Diverticulosis: outpatient therapy using bulking agents (>30 g/day) and/or fiber supplements Uncomplicated diverticulitis: outpatient therapy with or without oral antibiotics (exceptions below). For toxicity, septicemia, peritonitis, or inability of symptoms to go away, 1-2% of people need to be hospitalized. The initial episode of diverticulitis may necessitate surgery in up to 30% of patients. Diverticulitis that is complicated may require hospitalization, bowel rest, and IV antibiotics. Hinchey severity classification: Diverticulitis can progress through four stages: Stage I involves limited paracolic abscess, Stage II involves distal abscess, Stage III involves purulent peritonitis, and Stage IV involves fecal peritonitis. Symptomatic relief is anticipated in 2 to 3 days. For seven to ten days, antibiotics should be continued. Diverticular bleeding: In 80% of cases, it goes away on its own. The First Line of Medicine Diverticulosis with symptoms can be treated with either continuous mesalamine 800 mg PO BID or cyclical rifaximin 400 mg PO BID for 7 days each month. Diverticulitis acute - It is debatable whether or not uncomplicated diverticulitis should routinely be treated with antibiotics. - Oral antibiotics for outpatients: A fluoroquinolone (ciprofloxacin 750 mg BID or levofloxacin 750 mg QD) combined with metronidazole 500 mg TID (clindamycin may be used if metronidazole intolerance is present) or Trimethoprim/sulfamethoxazole DS BID in addition to 500 mg TID of metronidazole Treat for seven to ten days. Use IV antibiotics if you're a patient. Ertapenem (1 g IV QD), piperacillin/tazobactam (3,375 g IV QID), ampicillin/sulbactam (3 g IV q6h), or -lactam/-lactamase inhibitor monotherapy Quinolone (levofloxacin 750 mg IV QD with metronidazole 500 mg IV TID) for penicillin allergy patient Mesalamine, rifaximin, or probiotics may be used to lessen the likelihood of recurrent acute diverticulitis in patients with unresponsive or severe disease. Diverticular bleeding: Use a selective intra-arterial catheter and 0.2 to 0.3 U/min of vasopressin to treat the condition. Avoid morphine and other opiates that can raise intraluminal pressure or encourage ileus as a precaution. It is not advised to consume more fiber when managing diverticulitis acutely. Next Line Outpatient: Moxifloxacin (400 mg PO QD) + metronidazole (500 mg PO TID) or amoxicillin/clavulanate monotherapy (875/125 mg BID) (contraindicated in patients with clearance 30 mL/min). Severely unwell inpatients should receive either ampicillin + metronidazole + an aminoglycoside (500 mg IV q6h) or ampicillin + metronidazole + a quinolone (500 mg IV TID). Referral Following the remission of diverticulitis (6 to 8 weeks later), individuals with acute diverticulitis should visit a gastroenterologist or surgeon for a colonoscopy in order to rule out cancer, fistulas, strictures, or inflammatory bowel disease. Diverticulitis that is acute and complicated should have the proper surgical, critical care, and infectious disease consults. Acute diverticulitis - Peritonitis, uncontrolled sepsis, perforation, blockage are indications for emergency surgery. - Hinchey I and II: interventional radiology consultation to drain significant abscesses (>4 cm) - Hinchey III or IV: necessitates surgery repeatedly during the same hospital stay - The choice to do an elective colon resection for recurrent diverticulitis is made on a case-by-case basis and is often carried out during the quiescent stage after receiving the necessary nonoperative care. – Patients with immune deficiencies are more likely to arrive with acute severe diverticulitis, experience medical management failure, and experience post-operative problems. Diverticular bleeding: Angiography is preferable over endoscopy in unstable patients to locate the bleeding cause and embolize the feeding artery. Endoscopy and hemostasis via epinephrine injection, electrocautery, or clipping. – Limited or partial colectomy is needed to stop massive or recurrent bleeding. Various Therapies With varying degrees of efficacy, probiotics have been used to prevent recurrence. Admissions Admit for peritonitis (complicated diverticulitis), sepsis, or systemic poisoning. Consider admitting patients with simple diverticulitis who also meet the following criteria: they are elderly, immunosuppressed, have evidence of microperforation, have notable leukocytosis, have a temperature greater than 39 degrees, are unable to take in POs, have severe stomach discomfort, or have unreliable follow-up. Patient Monitoring for Continuous Care Follow up with outpatients every week until symptoms go away starting two to three days after starting antibiotic therapy. – If the disease progresses during the follow-up, further imaging and/or inpatient therapy may be needed. Colonoscopy should be done within 6 to 8 weeks, unless it was done recently. Diet During acute diverticulitis, bowel rest with NPO is advised; if stool function has returned, advance diet is tolerated. A high-fiber diet should be followed by patients who have diverticulosis or a history of diverticulitis in order to prevent recurrence. There is no need to stay away from popcorn and nuts. With early discovery and appropriate treatment, the prognosis is favorable. There is a 33% probability of diverticulitis returning after the initial bout. There is a 66% likelihood of subsequent recurrence after a second episode. The majority of problems happen during the initial diverticulitis attack. Recurrence is more common in younger individuals, and rebleeding can happen in up to 6% of cases. Complications obstruction, abscess, obstruction with peritonitis, colovesicular/colovaginal fistula, or bleeding
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