Diverticulitis
From Medical-Wiki
Diverticulosis is a condition characterized by small mucosal herniations protruding through the intestinal layers and smooth muscle along the natural openings created by the vasa recta or nutrient vessels in the wall of the colon. Each of these herniations forms a small outpouching that is called a diverticulum. The sigmoid colon has the highest concentration of diverticuli because it is the site of greatest intraluminal pressure.
When one or more of these diverticuli become inflamed, the condition is called diverticulitis, The process creating the inflammation is a collection of undigested food in the diverticulum, obstruction of the diverticular neck, dilation of the pouch secondary to mucous secretion and bacterial overgrowth, and eventual micro—or macro-perforation. The more serious cases involve abscess formation, rupture of the abscess and subsequent peritonitis. Fistulae to adjacent organs and the skin are also possible. Recurrent attacks may lead to narrowing of the colonic channel. [1]
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Clinical presentation
A typical case of diverticulitis presents with left lower quadrant (LLQ) pain, localized tenderness, and a low grade fever. If the disease is more extensive, patients may have peritoneal signs, high fever, more generalized abdominal pain, and an associated paralytic ileus. Particularly in the elderly with compromising comorbid medical problems, diffuse peritonitis may lead to shock and cardiovascular collapse.
Diagnosis
Clinical findings
Clinically, a palpable abdominal mass suggests the possibility of an abscess. Pneumaturia (air in urine) or fecaluria (fecal material in urine) suggest a colovesical fistula. Leukocytosis is a given unless there is some form of comorbid immunosuppression. CT scanning is now the preferred imaging technique, replacing barium enema. As noted by national guidelines, this procedure should be reserved for suspected abscesses or perforations, failure of medical therapy, or if a diagnosis is in doubt.
Laboratory findings
6 to 8 weeks following an acute attack, endoscopy and/or BE should be performed to evaluate the extensiveness of diverticuli as well as to evaluate for the possibility of colorectal carcinoma. [2]
Treatment
Hospitalization is indicated if there are signs of hypotension, cardiovascular compromise, peritonitis, or abscess. Treatment should consist of intravenous hydration, broad-spectrum antibiotics, and bowel rest with or without nasogastric tube decompression. Typically this will result in a resolution of pain, fever, and ileus with 2 to 3 days. Antibiotics should be continued for 7 to 10 days. Oral feedings should be restarted slowly and advanced as tolerated. Patients should initiate a high fiber diet when possible.
Emergency surgical exploration is indicated in patients who have diffuse peritonitis or pneumoperitoneum (air in the peritoneum). This should be performed after stabilization with fluids, initiation of antibiotics and stabilization of any comorbid cardiovascular problems. The surgical procedure of choice is resection of the perforated colonic segment (almost always the sigmoid) with descending end colostomy and closure of the rectal stump.
Elective surgery is indicated for “two or more acute attacks of diverticulitis successfully treated medically, a single attack requiring hospitalization in a patient less than 40 years of age, one attack with evidence of contained perforation, colonic obstruction, or inflammatory involvement of the urinary tract, inability to rule out a colonic carcinoma.” [3]
Elective surgery may almost always be accomplished via laparoscopic colectomy. Sometimes, significant adhesions, inflammation, bleeding, or other adversity may require conversion to an open exploration, but rather than a complication, this is simply an appropriate step for the avoidance of complications. [4]
