Rosen & Barkin's 5-Minute Emergency Medicine Consult (220 page)

Diverticulosis

CODES

• 562.11 Diverticulitis of colon (without mention of hemorrhage)
  
• 562.13 Diverticulitis of colon with hemorrhage
  

BASICS

• Single (diverticulum) or multiple (diverticula) colonic wall outpouchings from colonic muscle dysfunction, usually acquired
  
• Sequence:
  
  • Insufficient amounts of dietary fiber cause diminished stool bulk
    
  • Increased colonic contractions to propel stool through colon cause increase in intraluminal pressure
    
  • Increased pressure forces mucosa and submucosa to herniate through muscularis propria at its weakest point, where vasa recta penetrate
    

• Occurs anywhere in GI tract, although generally a colonic disease:
  
  • Left sided 95% (Western countries)
    
  • Right sided 70% (Asian countries)
    
  • Sigmoid colon most common site
    
• Pseudodiverticula:
  
  • Outpouchings of mucosa and submucosa only
    
  • Most common form of colonic diverticula
    
  • True congenital diverticula (uncommon) contain all bowel wall layers.
    
• Common in Western society, owing to refined diet and low intake of fiber
  
• Prevalence is age-dependent
  
  • 30% by 50 yr old, 65% by 85 yr old
    
• Complications
  
  • 70% are asymptomatic
    
  • 15–25% develop diverticulitis
    
  • 5–15% develop bleeding; obesity is a risk factor
    
    • Bleeding stops spontaneously in 75% of cases
      
  • Inflammation (diverticulitis)
    
  • Massive arterial bleeding usually from right colon:
    
    • Fecalith (dry, hard stool) erodes through arterial branch.
      
  • Perforation
    
  • Abscess
    
  • Obstruction
    

DIAGNOSIS

• Chronic or intermittent abdominal pain
  
  • Often precipitated by eating
    
  • Sometimes relieved by flatulence or bowel movement
    
• Change in bowel pattern
  
  • Constipation or diarrhea
    
• Dyspepsia
  
• Painless hematochezia; 75% self-limiting
  
  • Left colon origin: Bright red
    
  • Right colon origin: Dark or maroon colored, mixed with stool
    
• Diverticulitis and diverticular bleeding are separate entities and rarely coexist.
  

• Afebrile
  
• Abdomen typically benign, but presentation variable
  
  • Tenderness in left lower quadrant
    
  • Firm sigmoid colon in left lower quadrant
    
• Rectal exam variable
  
  • Heme-negative stool
    
  • Blood if diverticular bleed
    

Thorough history and physical exam essential to avoid excessive workup

• Asymptomatic diverticulosis
  
  • Requires no workup
    
• Recurrent uncomplicated painful disease
  
  • Requires no workup
    
• New onset uncomplicated painful disease
  
  • Requires workup to rule out carcinoma (if weight loss, anorexia, heme-positive stool)
    
  • CBC for leukocytosis or anemia
    
  • Urinalysis to exclude hematuria or pyuria
    
• Hemorrhagic diverticulosis
  
  • CBC
    
  • Electrolytes, BUN, creatinine, glucose, calcium
    
  • Type and cross for 4 units of packed RBCs
    
  • PT, PTT, INR
    
  • ECG
    

• Uncomplicated painful diverticulosis—outpatient options
  
  • Flexible sigmoidoscopy, then barium enema
    
    • Sigmoidoscopy: Rule out carcinoma (before barium studies for optimal visualization)
      
    • Barium enema: Search for classic diverticula and exclude carcinoma or polyps
      
  • Colonoscopy
    
• Hemorrhagic diverticulosis
  
  • Anoscopy
    
    • If mild bleeding, to rule out hemorrhoids
      
    • Massive bleeding from hemorrhoids is rare
      
  • Proctosigmoidoscopy
    
    • If no blood in stool above rectum, assume rectal bleed
      
  • Colonoscopy
    
    • Cannot perform if bleeding excessive (difficult to visualize pathology)
      
    • Allows for therapeutic intervention
      
    • Usually done prior to radionuclide imaging or angiography
      
  • Radionuclide imaging
    
    • Safe, no bowel prep needed
      
    • Poor localization of bleeding site
      
    • Ideal for detecting intermittent bleeding, owing to long half-life of radioisotope (24–36 hr)
      
    • No potential for therapeutic intervention, but helpful prior to angiography
      
  • Angiography
    
    • Helpful if bleeding site cannot be identified by colonoscopy; must be actively bleeding at least 0.5 mL/min
      
    • Localizes site of bleeding (more exact after radionuclide scanning)
      
    • Allows for therapeutic intervention
      
    • Risk of intestinal infarction
      
  • Barium enema
    
    • Rarely indicated, but most sensitive for diagnosis
      
    • Identifies diverticula but not bleeding (can hinder visualization of other imaging techniques)
      

• Painful diverticulosis
  
  • Irritable bowel syndrome (almost identical clinical presentation)
    
  • Diverticulitis
    
  • Colon carcinoma
    
  • Crohn's disease
    
  • Urologic (renal colic)
    
  • Gynecologic (ruptured or torsed ovarian cyst)
    
• Hemorrhagic diverticulosis
  
  • Hemorrhoids
    
  • Anal fissure
    
  • Proctitis
    
  • Colitis
    
  • Carcinoma
    
  • Polyps
    
  • Ischemic enteritis
    
  • Angiodysplasia
    
  • Amyloidosis
    
  • Vascular-enteric fistula
    
  • Upper GI source
    

TREATMENT

• Avoid opiates in abdominal pain when underlying cause is uncertain.
  
• Establish 2 large-bore IV lines
  
• For significant bleeding or hypotension:
  
  • 1–2 L (20 mL/kg) bolus 0.9% NS intravenously
    
  • Trendelenburg position
    

• Hemorrhagic diverticulosis (massive):
  
  • Airway control (100% O
    ₂
    or intubate if unresponsive)
    
  • Intravenous access with at least 1 large-bore catheter or 2 if unstable
    
  • 0.9% NS bolus 1–2 L (20 mL/kg) for hypotension
    
  • Central catheter placement if unstable following initial fluid resuscitation for more efficient delivery of fluids and monitoring of central venous pressure
    
  • Consider nasogastric tube to rule out upper GI bleed
    
  • Bladder catheter to monitor urine output
    
  • Transfuse O-negative RBCs immediately if arrest is impending
    
  • Consult surgeon for persistent bleeding, impending hemorrhagic shock (most diverticular bleeding stops spontaneously)
    

• Uncomplicated symptomatic diverticulosis
  
  • High-fiber diet and/or hydrophilic bulk laxative (i.e., psyllium)
    
  • Warm compresses to abdomen
    
  • Reassurance
    
  • Avoid cathartic laxatives
    
  • No evidence to support use of antispasmodic (dicyclomine)
    
• Hemorrhagic diverticulosis (massive):
  
  • Initial stabilization (see above)
    
  • Colonoscopy is diagnostic and potentially therapeutic
    
  • Radionuclide scan; sensitive and noninvasive, but requires active bleeding
    
  • Selective angiography with injection of vasopressin to control bleeding
    
  • Embolization, interventional radiology; consider before surgery
    
  • Surgical intervention for segmental colectomy
    

• Dicyclomine: 20 mg PO/IM QID (not for IV use)
  
• Propantheline: 15 mg PO 30 min ac/qhs
  

FOLLOW-UP