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Diverticulitis

Diverticulitides

Diverticulitis is a disease of the gastrointestinal tract. It is mainly a disease of the elderly when diverticula get infected.


Presentation

The commonest presenting symptom of diverticulitis is pain. Pain is usually left sided in the left lower quadrant region because this is the most common site for diverticula formation. Fever and other signs of systemic infection may be present if the disease progresses and leads to formation of localized abscess.

Other symptoms are:

The disease could mimic various types of gastrointestinal conditions because of the ability of diverticulosis to occur anywhere along the tract. On physical examination, there is:

Pain
  • Twenty-two (6.9%) patients were admitted for 7 days; this was associated with patient-reported pain score 8/10 (OR 5.67).[ncbi.nlm.nih.gov]
  • Abdominal pain is the most common complaint in patients with acute diverticulitis. The pain can be described as cramping, constant, and persistent for several days. Medical management is most often provided with antibiotics and clear liquid diet.[ncbi.nlm.nih.gov]
  • Symptoms The signs and symptoms of diverticulitis include: Pain, which may be constant and persist for several days. The lower left side of the abdomen is the usual site of the pain.[mayoclinic.com]
  • Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis.[ncbi.nlm.nih.gov]
Fever
  • Fever. Abdominal tenderness. Constipation or, less commonly, diarrhea. When to see a doctor Get medical attention anytime you have constant, unexplained abdominal pain, particularly if you also have fever and constipation or diarrhea.[mayoclinic.com]
  • Its symptoms are pain and tenderness in the lower left side of the abdomen, chills, and sometimes fever. The presence of diverticulitis can be determined by X rays or computed tomography (CT) scans.[britannica.com]
  • People who have increasing pain, tenderness, and fever also need surgery. The surgeon removes the involved section of the intestine.[merck.com]
  • CASE REPORT: Here we present a female patient with a history of right lower abdominal pain and fever of 3 days duration. She was diagnosed with acute appendicitis according to the preoperative physical, laboratory, and imaging examinations.[ncbi.nlm.nih.gov]
Anemia
  • A blood laboratory revealed severe anemia increased CRP (11.21 mg/dl). The upper and lower gastrointestinal endoscopic examination revealed no significant changes. The colon was free from diverticulum.[ncbi.nlm.nih.gov]
  • At times diverticulosis can result in severe hemorrhage and anemia. Altogether, these problems or advanced conditions associated with diverticular disease are prevented with minimally invasive, surgical removal of the affected portion of the colon.[sassesurgical.com]
  • If a very small amount leaks out continually, it can still add up over time and cause mild anemia. Bleeding that doesn't stop always requires treatment.[medbroadcast.com]
  • […] increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine Documented hypersensitivity; megaloblastic anemia[web.archive.org]
Rigor
  • Effective medical strategies for prevention of recurrent diverticulitis are needed, and further randomised, double-blinded, placebo-controlled trials of rigorous design are warranted to specify the effects of 5-ASA (mesalamine) in the management of diverticulitis[ncbi.nlm.nih.gov]
  • The relatively low number of patients meeting the inclusion criteria also limits a rigorous assessment of its merits.[doi.org]
Fatigue
  • A feeling of low energy and fatigue is also often present. Treatment Medication for ulcerative colitis can suppress the inflammation of the colon and allow for tissues to heal.[empowher.com]
Severe Clinical Course
  • This retrospective study aimed to identify risk factors for severe clinical course in patients with uncomplicated AD.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis.[ncbi.nlm.nih.gov]
  • Here, we report an ectopic paragonimiasis case initially presented with recurrent abdominal pain.[ncbi.nlm.nih.gov]
  • Severe abdominal pain is a common complaint encountered by primary care and emergency room physicians. Caused by many conditions, including appendicitis and diverticulitis, severe abdominal pain may be a diagnostic challenge.[doi.org]
Constipation
  • However, patients who have a high fiber diet, those who are obese, frequently constipated ones and older people tend to develop these pouches.[symptoma.com]
  • Constipation or, less commonly, diarrhea. When to see a doctor Get medical attention anytime you have constant, unexplained abdominal pain, particularly if you also have fever and constipation or diarrhea.[mayoclinic.com]
  • You ask about the use of charcoal for diverticulosis: because constipation figures so prominently in the formation of diverticula, and because charcoal tends to be binding or constipating for many, I would choose to focus more on lifestyle issues than[charcoalremedies.com]
Vomiting
  • Blood chemistry to examine the levels of electrolytes in patients who have been vomiting.[symptoma.com]
  • There was reasonable quality of evidence suggesting that high C-reactive protein; white blood cell count; clinical signs including generalized abdominal pain, constipation and vomiting; steroid usage; a primary episode; and comorbidity are risk factors[ncbi.nlm.nih.gov]
  • There can also be nausea and vomiting with cramping and chills. Acute diverticulitis is when there is a flare up or onset of symptoms.[diverticulitisinfo.com]
  • See your doctor immediately if you have: very severe abdominal pain a fever start vomiting feel very unwell have blood in your poo Diverticulitis diagnosis To diagnose diverticulitis, your doctor will talk to you and examine you.[healthdirect.gov.au]
  • Also seek medical attention if you have a fever, the pain gets worse, and you have consistent vomiting or lack of bowel movements.[diet.lovetoknow.com]
Rectal Bleeding
  • We describe a 9-year-old boy with Williams syndrome who presented with rectal bleeding secondary to sigmoid diverticulitis. This case represents the youngest known patient with diverticulitis.[ncbi.nlm.nih.gov]
  • The symptoms include pain, often accompanied by fever, a change in bowel patterns and, sometimes, rectal bleeding. "For someone with diverticulitis, blackberries are bad.[web.archive.org]
Lower Abdominal Pain
  • CASE REPORT: Here we present a female patient with a history of right lower abdominal pain and fever of 3 days duration. She was diagnosed with acute appendicitis according to the preoperative physical, laboratory, and imaging examinations.[ncbi.nlm.nih.gov]
  • The usual symptoms of diverticulitis include: fever, lower abdominal pain, and lower abdominal tenderness.[uphs.upenn.edu]
  • A previously healthy 45-year-old man presents with severe lower abdominal pain on the left side, which started 36 hours earlier. He has noticed mild discomfort in this region periodically before but has not sought medical treatment.[nejm.org]
  • Left lower abdominal pain, tenderness, and fever are the typical symptoms. The diagnosis is based on the results of a computed tomography (CT) scan, and colonoscopy is done after the episode of diverticulitis is over.[msdmanuals.com]
Pelvic Pain
  • Pain causes (including pregnancy-related) Avoid Colonoscopy in acute disease Risk of worsening perforation Avoid Barium Enema in acute disease Risk of extravasation if perforation XI.[fpnotebook.com]

Workup

Laboratory tests

They are used when the history and physical examination are inconclusive. They include:

  • Complete blood count will show increased white blood cell count and reduced hemoglobin if bleeding is present.
  • Blood chemistry to examine the levels of electrolytes in patients who have been vomiting.
  • Renal function [6]
  • Test for liver function and liver enzymes 
  • Blood culture should be obtained before instituting antibiotics
  • Pregnancy test  to rule out other conditions like extra-uterine pregnancy in a woman of childbearing age
  • Urinalysis
  • Urine culture

Imaging

  • CT scan, when necessary, this is the imaging study of choice. Findings include inflammatory masses and bowel wall thickening.
  • Contrast studies: Barium us contraindicated as there may be perforations and leakage of contrast into the peritoneal cavity could be disastrous. A water soluble contrast medium is preferred when a CT scan can’t adequately differentiate colon cancer from diverticulitis.
  • Plain radiographs have no use in diagnosing this condition but may demonstrate associated obstruction and bowel perforation [7].
  • Colonoscopy can be used after an acute episode to check the extent of the diverticulosis.
Paragonimus Westermani
  • When infected with Paragonimus westermani, which is the dominant species in Korea, the central nervous system is frequently involved along with the liver, intestine, peritoneal cavity, retroperitoneum, and abdominal wall.[ncbi.nlm.nih.gov]

Treatment

In patients with the acute uncomplicated type, conservative management achieves full remission in over 70% of cases. Some studies have shown that antibiotics worsen the inflammatory process. Conservative management includes:

  • Clear liquid diet
  • Resting the bowel
  • IV fluids
  • Managing the pain

Antibiotics, if used, are broad spectrum to cover aerobic and non-aerobic organisms. This could be a single or multi drug regimen. If diverticulitis is severe, as characterized by peritonitis and systemic signs of infection, hospitalization is required [8].

Surgery is indicated when there is a complication. Complications may include intestinal obstruction, presence of fistula, abscesses and peritonitis. At discharge, patient’s diet should be low in fat and high in fiber.

Prognosis

The following factors may worsen the prognosis:

  • Coexisting medical problems
  • The presence of complications
  • Severity of the illness [4]

Etiology

The cause if diverticula formation is yet unclear. There is however strong association with obesity, low fiber diet and constipation. When these pouches are present, there are now factors that could lead to inflammation and hence diverticulitis. Although the exact pathway by which diverticulitis occurs is unclear, there have been some postulations [2]:

  • Collection of undigested food particles in the diverticulum
  • Collection of fecal matter in the diverticulum
  • Raised intraluminal pressure 
  • Thickened food particles

Epidemiology

Diverticulitis is mainly a disease of the elderly although it is now seen in younger age groups as well. The incidence increases with advancing age and 65% of people older than 85 years have diverticulitis. There is no sexual preference as the disease affects both sexes equally.

It is more common in industrialized countries compared to underdeveloped countries. This could be due to lifestyle and diet. It is seen more Caucasians and Asians than in blacks.

Sex distribution
Age distribution

Pathophysiology

There are two ways by which diverticulosis is thought to occur. The first is erosion of the wall of the diverticula which leads to inflammation, necrosis and then perforation.
The second mechanism, which is also touted to be the commonest is obstruction of the diverticulum lumen. This obstruction is usually by undigested food particles or fecal matter. The obstruction then leads to distension due to mucus secretion within the diverticulum. Subsequently, the blood supply is compromised and this will cause perforations, both micro and macro, of the diverticulum[3].

Chronic diverticulitis could lead to fistula formation. Frequent bouts of diverticulitis can also cause intestinal obstruction when it causes scar formation which obstructs the colonic lumen.

Prevention

In patients with risk for diverticulosis, and in those with asymptomatic types, the standard of prevention is a high-fiber diet [9].

Summary

In some people, there is some herniation of mucosa into the wall of the colon. This creates small pouches which are known as diverticula and the condition is known as diverticulosis. When one or more of this pouches get inflamed, it is called diverticulitis. Diverticulitis could be acute or chronic and it includes a wide range of conditions from asymptomatic forms to symptomatic forms [1].

Patient Information

Definition

Diverticulitis is a condition that results from inflammation of diverticula in the intestines. Diverticula are abnormal pouches that form on the walls of the intestines.

Cause

There is no clear cause. However, patients who have a high fiber diet, those who are obese, frequently constipated ones and older people tend to develop these pouches. When this pouches are present, they can be blocked by food or fecal particle which could lead to the processes causing diverticulitis.

Signs and symptoms

The commonest symptom of this disease is abdominal pain. It is usually on the left, like appendicitis but on the other side. Other symptoms include nausea, vomiting, diarrhea, increased flatulence, and constipation amongst others.

Diagnosis

Diagnosis is mainly by history and the examination by the doctor. Some laboratory tests like blood and urine tests may be done to check severity of the disease and the function of some organs in the body. Some imaging tests may also be carried out [10].

Treatment

For the mild type, treatment is conservative and patient may or may not require antibiotics. For the sever type, hospital stay would be necessary for close monitoring and patient may require surgery.

References

Article

  1. Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. Jan 2009;136(1):115-122.e1.
  2. Miller FH, Bree RL, Rosen MP, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria left lower quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008
  3. Alonso S, Pera M, Pares D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis.Colorectal Dis. Nov 10 2009
  4. Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, et al. Complicated diverticulitis: is it time to rethink the rules?. Ann Surg. Oct 2005;242(4):576-81; discussion 581-3.
  5. Evans JP, Cooper J, Roediger WE. Diverticular colitis - therapeutic and aetiological considerations.Colorectal Dis. May 2002;4(3):208-212.
  6. Oliver G, Lowry A, Vernava A, Hicks T, Burnstein M, Denstman F, et al. Practice parameters for antibiotic prophylaxis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum. Sep 2000;43(9):1194-200.
  7. Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. Jul 2006;49(7):939-44.
  8. Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208 patients. Eur Radiol. Dec 2003;13(12):2587-95
  9. Schreyer AG, Furst A, Agha A, Kikinis R, Scheibl K, Scholmerich J, et al. Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis. Sep 2004;19(5):474-80.
  10. Ambrosetti P, Robert JH, Witzig JA, Mirescu D, Mathey P, Borst F, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg. Aug 1994;179(2):156-60.

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Last updated: 2019-07-11 22:03