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Diverticular Disease
Tonya Kaltenbach, Roy Soetikno

Introduction
Diverticular disease is common. Its prevalence increases with age, from less than 10% in persons younger than 40 years of age, to up to 66% in elderly patients over the age of 80 years. It has an estimated mortality rate of 2.5 per 100 000 per year. Diverticulae are caused by alterations in colonic wall structure, colonic dysmotility and dietary ber deciencies. They typically occur between the taeniae coli due to weaknesses of the circular muscle layer at sites of penetration of the vasa recta. Most patients with diverticulosis are asymptomatic throughout their lifetime. About 20% of patients, however, may develop complications of diverticulosis such as diverticulitis with infection, abscess, stula, obstruction and perforation; or diverticular bleeding.

Presentation
Visceral abdominal pain with tenderness localized to area of maximal inammation Nausea, vomiting and altered bowel habits Rectal tenderness Fever Leukocytosis

Evaluation
Complete blood count Radiographs erect chest: assess for pneumoperitoneum supine abdomen: assess for bowel dilation, ileus, pneumoperitoneum, obstruction or soft tissue densities to suggest an abscess Urinalysis: assess for colovesicular stula CT (computed tomography) abdomen and pelvis with intravenous, oral and rectal contrast pericolic fat inltration thickened fascia muscular hypertrophy Barium enema and endoscopy are generally avoided due to potential to exacerbate a perforation. The diagnosis of diverticulitis should be suspected and made primarily on the basis of the history and physical examination. When the clinical picture is clear, additional tests are not necessary to make a diagnosis. In cases of uncertainty, a CT should be performed for conrmation.

Diverticulitis Natural history

Acute diverticulitis is the most common clinical complication of diverticular disease. Hospitalization is required in less than 10% of diverticulitis attacks. With conservative management, 80% improve, and most patients have no future problems. Risk of recurrent symptoms, however, has been reported in up to 45% of patients. Recurrent attacks are less likely to respond to medical treatment and are associated with a high mortality rate. Elective resection is therefore considered after two attacks of uncomplicated diverticulitis.

Management
Outpatient Patients with a mild presentation, ability to tolerate oral intake, low severity of illness and adequate support can be treated as an outpatient with: clear liquid diet broad-spectrum antibiotics for 710 days amoxicillin-clavulanate or

Gastrointestinal Emergencies, 2nd Edition. Edited by T. C. K. Tham, J. S. A. Collins and R. M. Soetikno 2009 Blackwell Publishing Ltd. ISBN: 978-1-405-14634-0

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SECTION 3 Specic Conditions

trimethoprim-sulfamethoxazole or uoroquinolone metronidazole Symptomatic improvement should be appreciated within several days.

Hospitalized Patients with a more severe attack of diverticulitis may require hospitalization with: analgesia bowel rest intravenous uid broad-spectrum antibiotics for 710 days anaerobes: metronidazole or clindamycin plus gram negative rods: aminoglycoside or monobactam or third-generation cephalosporin

Distant or unresolving abscesses Interventional CT or US-guided percutaneous palliative drainage surgical single-stage resection and anastomosis (eliminates need for two-stage surgical procedure with interval colostomy)

Fistula
Natural history
A stula may form when a diverticular abscess extends into an adjacent organ. The most common diverticular stula is colovesicular. Only about onehalf of patients diagnosed with a diverticular stula have a history of diverticulitis.

Presentation Complicated diverticulitis

Complications of diverticulitis include abscess, stula, obstruction and perforation. Symptoms suggestive of preceding abscess abdominal pain fever weight loss Location of stula colovesicular: pneumaturia, fecaluria, urosepsis colovaginal: perineum irritation, infections or feculent discharge coloenteric: malabsorption and diarrhea from bacterial overgrowth colocutaneous: abdominal wall irritation

Abscess
Natural history
Abscesses complicate about 10% of acute diverticulitis episodes, and have an estimated 12% mortality.

Presentation
Episodic fevers Weight loss Leukocytosis Pain localized to visceral and parietal innervation of the abscess wall Dysuria, urinary frequency, tenesmus, dyspareunia in pelvic collections

Evaluation
The diagnostic yield of each modality varies widely. Colonoscopy Barium enema Fistulography Cystoscopy Computed tomography accurately predicts the presence of a stula: local colonic thickening adjacent to an area of thickened organ associated diverticula oral contrast material or air in the organ

Evaluation
Computed tomography

Management
Small pericolic Conservative bowel rest intravenous uids broad-spectrum antibiotics Intervention if not responsive to conservative CT or ultrasound (US)-guided percutaneous drainage surgical single-stage resection and anastomosis
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Management
Surgical single-stage stula closure with resection of diseased colon and anastomosis and repair of contiguous organ. In those patients with severe co-morbid conditions, conservative therapy may be considered, eg prophylactic antibiotics for colovesical stula.

CHAPTER 32 Diverticular Disease

Obstruction
Natural history
Intestinal obstruction is uncommon in diverticulitis, occurring in approximately 2% of patients. It may present in an episode of acute diverticulitis due to luminal narrowing caused by inammation or compression by an abscess. Recurrent episodes of subclinical diverticulitis can result in progressive brosis and stricturing of the colonic wall without associated inammation. Small bowel obstruction is usually the result of adhesions.

Evaluation
Complete blood count Serum electrolytes Arterial blood gas Radiograph Close surgical monitoring

Management
Bowel rest Aggressive intravenous uids Broad-spectrum antibiotics Surgery

Presentation (see Chapter 19)

Nausea Vomiting Weight loss Distention

Diverticular hemorrhage Natural history

Diverticulosis remains the most frequent cause of lower gastrointestinal bleeding, and presents as acute, painless hematochezia, often in elderly patients with comorbid conditions including hypertension, ischemic heart disease, diabetes and who use oral anticoagulation or antiplatelet medication. Diverticulae are located in the colonic wall at the sites of penetrating nutrient vessels. Bleeding is arterial and can occur either at the dome or the neck of the diverticulum. It is important to recognize the various stigmata of diverticular bleeding including large and small vessel, adherent clot, at pigmented spot and erosion.

Evaluation
Fluid status Electrolytes Radiograph Endoscopy to assess stricture and exclude malignancy

Management
Conservative bowel rest intravenous uids broad-spectrum antibiotics Intervention endoscopic dilation endoscopic stenting: palliative, or decompression prior to elective surgery surgical resection

Presentation
Abrupt, voluminous, painless hematochezia

Evaluation
Stratication Most acute diverticular bleeding is self-limiting. In general, patients with stable vital signs, no recent bloody efuent and no syncope have a low risk of continued bleeding and elective colonoscopy is appropriate. Urgent interventions should be targeted for patients with severe bleeding. Independent correlates of severe bleeding include: bleeding per rectum during the rst 4 hours of evaluation vital sign instability tachycardia (HR 100) hypotension (SBP 115 mmHg) syncope nontender abdominal examination
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Perforation (see Chapter 19)

Natural history
Over 20% of patients hospitalized with diverticular disease have peritonitis due to a perforation. It is associated with a mortality rate as high as 35% and requires urgent surgical evaluation.

Presentation
Severe acute abdominal pain Dehydration Fever Tachycardia Generalized tenderness with guarding Absent bowel sounds

SECTION 3 Specic Conditions

aspirin use 2 comorbid conditions. Check Complete blood count Assess Volume status Exclude an upper gastrointestinal source Upper endoscopy patients with a positive nasogastric aspirate patients where a colonic source is not identied.

twelve published small studies have shown high rates of successful primary hemostasis in patients with active bleeding. Short-term, less than 1 week, rebleeding rates were, however, high, found to be about 25% with a mean of 1053%; and data on long-term rebleeding rates is lacking. Ischemia was notably reported in close to 20% of patients despite using smaller catheter and more directed therapy.

Management
Once the patient has been resuscitated, the severity of bleeding assessed, and an upper gastrointestinal source of bleeding excluded, urgent colonoscopy should be performed. In cases of continued bleeding not amenable to endoscopic therapy, angiography or surgery should be considered.

Surgery Whenever possible, it is preferable to perform surgery on an elective basis rather than emergently. Operative mortality is 10% even with accurate localization and up to 57% with blind subtotal colectomy.

Further reading
Colonoscopy Available data suggest that endoscopic intervention for diverticular hemorrhage is safe and likely to be benecial. Rapid purge preparation with polyethylene glycolbased solutions Administer by a nasogastric tube or by drinking 1 L every 3045 min Median dose of 5.5 L (range 414 L) over 34 hours Metoclopramide, 10 mg iv, before starting the purge to control nausea and promote gastric emptying Nasogastric suction immediate prior to colonoscopy Contraindications: bowel obstruction, gastroparesis Techniques Mechanical methods are preferred. (a) Clip marking for future localization; direct application to neck or dome; use of a cap may facilitate therapy. (b) Band ligation Coagulation: generally avoided at the dome due to perforation concern Injection: reported with limited success Technetium scan Literature dating since 1990 suggests that technetium scans are not particularly useful to conrm and localize the bleeding site in order to direct further angiographic or surgical intervention. Angiography Angiography techniques have been modied over time to use smaller catheters for coiling or gel foam embolization. Using this optimal embolization technique,
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