QUICK RECERTIFICATION SERIES
Diverticular disease Johanna L. Chelcun, MHS, PA-C; Thomas D’Addario, MSW
GENERAL FEATURES • Colonic diverticular disease is a condition in which intestinal mucosal layers protrude through a defect in the smooth muscle layer. { Results from increased pressure within the bowel { Associated with low-fiber diet, chronic constipation, and obesity { More common with older age but incidence has increased in younger population in recent years • Diverticular bleeding occurs from vasa recta arteries at the weak point where they penetrate the bowel wall. { Most common cause of hematochezia • Diverticulosis commonly occurs in the sigmoid colon due to its decreased diameter and higher intraluminal pressure; however, more than half of diverticular bleeds occur in the ascending colon. • Diverticulitis is localized inflammation of a diverticulum. { Increased pressure or luminal obstruction leads to distension, ischemia, and microperforation of tissue. { Occurs in 10% of patients with diverticulosis { Can progress to macroperforation, abscess, fistulae, and peritonitis { Multiple episodes may lead to colonic scarring and strictures. CLINICAL ASSESSMENT • Diverticulosis itself is asymptomatic. • Diverticular bleeding presents with painless hematochezia, bloating, cramping, or urge to defecate. • Diverticulitis presents with fever and cramping abdominal pain, usually of the left lower quadrant. { Diarrhea, constipation, nausea, or vomiting may occur. { If right-sided, diverticulitis can mimic signs and symptoms of acute appendicitis. { Abdominal examination may reveal normal or decreased bowel sounds, distension, or tenderness. { Guarding and rebound tenderness are signs of acute peritonitis. Johanna L. Chelcun is a clinical assistant professor at Quinnipiac University in Hamden, Conn., and practices at Yale-New Haven Hospital in New Haven, Conn. Thomas D’Addario is a student in the school of medicine at the University of Connecticut in Farmington. The authors have disclosed no potential conflicts of interest, financial or otherwise. Dawn Colomb-Lippa, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000456580.39509.e3 Copyright © 2014 American Academy of Physician Assistants
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www.JAAPA.com
DIAGNOSIS • Laboratory studies are nonspecific; leukocytosis with left shift may indicate diverticulitis but is not always present. • Colonoscopy is used to diagnose diverticulosis and diverticular bleeding, but should not be performed when diverticulitis is suspected due to risk of perforation. • In patients with gastrointestinal bleeding of unknown source, tagged red blood cell scan or CT angiography may reveal source of bleeding. • CT scan is the imaging method of choice for acute diverticulitis. { CT findings include presence of diverticuli, colonic wall thickening, and pericolic soft tissue changes. { Complications visible on CT include abscesses, fistulae, bowel obstruction, or signs of perforation (free air). • Abdominal flat plate can also be used to evaluate for bowel obstruction or perforation.
QUESTIONS 1. A 76-year-old man presents with a 2-day history of intermittent left lower quadrant abdominal pain. Which feature from the patient’s history, physical, and laboratory evaluation is most suggestive of colonic perforation? a. hematochezia b. rebound tenderness c. fever d. leukocytosis 2. A 60-year-old woman presents to the ED with abdominal pain and reports a history of intermittent hematochezia. Because she has a history of hemorrhoids, she has not sought medical advice until now. Her vital signs are BP, 118/86 mm Hg; pulse, 90 beats/minute; and temperature, 101.8° F (38.8° C). An abdominal examination reveals hypoactive bowel sounds, distension, and mild tenderness. She has no guarding or rebound tenderness. Laboratory studies reveal leukocytosis. Which is the most appropriate next step? a. IV ceftriaxone b. CT scan of the abdomen c. emergent surgery d. colonoscopy
Volume 27 • Number 12 • December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Diverticular disease {
Patients with recurrent episodes of diverticulitis may need elective surgical resection of the affected area.
2. B. The patient has signs of diverticulitis. The most appropriate test would be a CT scan of the abdomen, which would show evidence of diverticular disease and inflammation. Antibiotics are indicated in most cases of diverticulitis. Although perforation and peritonitis are concerns in patients with diverticulitis, this patient has no rebound tenderness or guarding, and emergent surgery would be premature. Because of the risk of perforation, colonoscopy is not done in patients with suspected diverticulitis. 1. B. Rebound tenderness raises concern for peritonitis caused by bowel perforation. Hematochezia is associated with diverticular bleeding; fever and leukocytosis can occur in uncomplicated diverticulitis.
Answers
TREATMENT • Increasing dietary fiber may reduce incidence of disease, but may not reduce symptoms in presence of diverticular disease. • Diverticular bleeding is usually self-limited; may require localized therapy or surgical intervention. { Endoscopic treatment options include epinephrine injection, clipping, or band ligation. { Intra-arterial vasopressin may be infused during angiography. { Blood transfusion may be needed if significant hemorrhage occurs. • Treatment of diverticulitis includes bowel rest, hydration, and oral or IV antibiotics. { New evidence suggests that in certain cases of uncomplicated diverticulitis, antibiotic therapy may not change patient outcomes, and patients may be managed conservatively. { Percutaneous drainage or surgical intervention is indicated in patients with abscess formation or peritonitis.
Visit www.jaapa.com to read more Quick Recertification Series articles. Choose the Article Collections tab and click on Quick Recertification Series.
JAAPA Journal of the American Academy of Physician Assistants
www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
45
Diverticular disease Johanna L. Chelcun, MHS, PA-C; Thomas D’Addario, MSW
GENERAL FEATURES • Colonic diverticular disease is a condition in which intestinal mucosal layers protrude through a defect in the smooth muscle layer. { Results from increased pressure within the bowel { Associated with low-fiber diet, chronic constipation, and obesity { More common with older age but incidence has increased in younger population in recent years • Diverticular bleeding occurs from vasa recta arteries at the weak point where they penetrate the bowel wall. { Most common cause of hematochezia • Diverticulosis commonly occurs in the sigmoid colon due to its decreased diameter and higher intraluminal pressure; however, more than half of diverticular bleeds occur in the ascending colon. • Diverticulitis is localized inflammation of a diverticulum. { Increased pressure or luminal obstruction leads to distension, ischemia, and microperforation of tissue. { Occurs in 10% of patients with diverticulosis { Can progress to macroperforation, abscess, fistulae, and peritonitis { Multiple episodes may lead to colonic scarring and strictures. CLINICAL ASSESSMENT • Diverticulosis itself is asymptomatic. • Diverticular bleeding presents with painless hematochezia, bloating, cramping, or urge to defecate. • Diverticulitis presents with fever and cramping abdominal pain, usually of the left lower quadrant. { Diarrhea, constipation, nausea, or vomiting may occur. { If right-sided, diverticulitis can mimic signs and symptoms of acute appendicitis. { Abdominal examination may reveal normal or decreased bowel sounds, distension, or tenderness. { Guarding and rebound tenderness are signs of acute peritonitis. Johanna L. Chelcun is a clinical assistant professor at Quinnipiac University in Hamden, Conn., and practices at Yale-New Haven Hospital in New Haven, Conn. Thomas D’Addario is a student in the school of medicine at the University of Connecticut in Farmington. The authors have disclosed no potential conflicts of interest, financial or otherwise. Dawn Colomb-Lippa, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000456580.39509.e3 Copyright © 2014 American Academy of Physician Assistants
44
www.JAAPA.com
DIAGNOSIS • Laboratory studies are nonspecific; leukocytosis with left shift may indicate diverticulitis but is not always present. • Colonoscopy is used to diagnose diverticulosis and diverticular bleeding, but should not be performed when diverticulitis is suspected due to risk of perforation. • In patients with gastrointestinal bleeding of unknown source, tagged red blood cell scan or CT angiography may reveal source of bleeding. • CT scan is the imaging method of choice for acute diverticulitis. { CT findings include presence of diverticuli, colonic wall thickening, and pericolic soft tissue changes. { Complications visible on CT include abscesses, fistulae, bowel obstruction, or signs of perforation (free air). • Abdominal flat plate can also be used to evaluate for bowel obstruction or perforation.
QUESTIONS 1. A 76-year-old man presents with a 2-day history of intermittent left lower quadrant abdominal pain. Which feature from the patient’s history, physical, and laboratory evaluation is most suggestive of colonic perforation? a. hematochezia b. rebound tenderness c. fever d. leukocytosis 2. A 60-year-old woman presents to the ED with abdominal pain and reports a history of intermittent hematochezia. Because she has a history of hemorrhoids, she has not sought medical advice until now. Her vital signs are BP, 118/86 mm Hg; pulse, 90 beats/minute; and temperature, 101.8° F (38.8° C). An abdominal examination reveals hypoactive bowel sounds, distension, and mild tenderness. She has no guarding or rebound tenderness. Laboratory studies reveal leukocytosis. Which is the most appropriate next step? a. IV ceftriaxone b. CT scan of the abdomen c. emergent surgery d. colonoscopy
Volume 27 • Number 12 • December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Diverticular disease {
Patients with recurrent episodes of diverticulitis may need elective surgical resection of the affected area.
2. B. The patient has signs of diverticulitis. The most appropriate test would be a CT scan of the abdomen, which would show evidence of diverticular disease and inflammation. Antibiotics are indicated in most cases of diverticulitis. Although perforation and peritonitis are concerns in patients with diverticulitis, this patient has no rebound tenderness or guarding, and emergent surgery would be premature. Because of the risk of perforation, colonoscopy is not done in patients with suspected diverticulitis. 1. B. Rebound tenderness raises concern for peritonitis caused by bowel perforation. Hematochezia is associated with diverticular bleeding; fever and leukocytosis can occur in uncomplicated diverticulitis.
Answers
TREATMENT • Increasing dietary fiber may reduce incidence of disease, but may not reduce symptoms in presence of diverticular disease. • Diverticular bleeding is usually self-limited; may require localized therapy or surgical intervention. { Endoscopic treatment options include epinephrine injection, clipping, or band ligation. { Intra-arterial vasopressin may be infused during angiography. { Blood transfusion may be needed if significant hemorrhage occurs. • Treatment of diverticulitis includes bowel rest, hydration, and oral or IV antibiotics. { New evidence suggests that in certain cases of uncomplicated diverticulitis, antibiotic therapy may not change patient outcomes, and patients may be managed conservatively. { Percutaneous drainage or surgical intervention is indicated in patients with abscess formation or peritonitis.
Visit www.jaapa.com to read more Quick Recertification Series articles. Choose the Article Collections tab and click on Quick Recertification Series.
JAAPA Journal of the American Academy of Physician Assistants
www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
45
