Diverticulitis overview: Difference between revisions
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An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis. | |||
===Surgery=== | ===Surgery=== | ||
Revision as of 20:43, 12 June 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Cafer Zorkun, M.D., Ph.D. [2]
Overview
Diverticulitis is a common digestive disease particularly found in the colon (the large intestine).[1] Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed or infected.[2] The colon can become infected with craters of food stuck inside, which causes abdominal pain.
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Diverticulitis overview from Other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications, and Prognosis
Natural History
Complications
Prognosis
Diagnosis
History and Symptoms
When taking a medical history, the doctor may ask about bowel habits, pain, other symptoms, diet, and medications. The physical exam usually involves a digital rectal exam. To perform this test, the doctor inserts a gloved, lubricated finger into the rectum to detect tenderness, blockage, or blood. The doctor may check stool for signs of bleeding and test blood for signs of infection.
Physical Examination
Diverticulitis diagnosis depends on taking a proper history and doing physical examination. The known diagnostic criteria for diverticulitis includes abdominal tenderness especially in the left lower quadrant, leukocytosis and CT scan findings helps in disease confirmation. Fever is common in diverticulitis patients. Abdominal examination will reveal tenderness, decreased bowel sounds and palpable mass may be felt. In some patients, genitourinary signs of cystitis would occur due to bladder irritation.[3]
Laboratory Findings
Diverticulitis diagnosis starts by taking history precisely and perform physical examination. Lab tests are important in excluding other causes of abdominal pain and any other gastrointestinal disease. These lab tests include CBC, CRP, urinalysis and liver tests. Imaging procedures are important measures in diagnosing diverticulitis including the CT scan and colonoscopy.[4][5]
CT scan
The CT scan is very sensitive (98%) in diagnosing diverticulitis. Using oral or intravenous contrast will have a good impact on the CT scan accuracy. It may also identify patients with more complicated diverticulitis, such as those with an associated abscess. CT also allows for radiologically guided drainage of associated abscesses, possibly sparing a patient from immediate surgical intervention. CT scan is not only important in the diagnosis of diverticulitis but also needed to exclude the cancer possibility in these patients.[6][7][8][9][10]
MRI
MRI is a good imaging modality that can be used in diagnosis of diverticulitis since it has an advantage that there is no exposure to the radiation and it rules out other abdominal causes of acute abdomen. However, it is not the best diagnostic procedure to diagnose diverticulitis and CT scan is more preferred. MRI shows specific findings of diverticulitis which include thickening of the colon wall, presence of the diverticula, and exudates out of the colon. It may also shows presence of multiple abscesses.[11][12]
Ultrasound
Meckel's diverticula are usually seen as tubular incompressible blind ending hypoechoic structure with irregular margins. Occasionally it may also be seen as a cyst, raising a different differential diagnosis of intestinal duplication which however is said to have regular margin.
X ray
X ray is a supportive diagnostic modality to diverticulitis although it is not the best modality. It can be used in case the CT scan is not available and in the uncomplicated cases. The radiographies used are the abdominal x ray, barium enema and the chest x-ray. The barium enema has disadvantages as if rupture happens, it will cause peritonitis. Abdominal x-ray shows multiple air and fluid levels in case of intestinal perforation. Chest x-ray is important to be done in patients with diverticulitis to investigate for the pneumoperitoneum which is a harbinger to a critical illness and will lead to change in the management plan in the case.
Other imaging findings
There are no other specific imaging findings for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Other diagnostic studies
There are no other specific diagnostic studies for diverticulitis. Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Treatment
Medical Therapy
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis.
Surgery
Prevention
References
- ↑ Diverticulosis and Diverticulitis. National Institute of Health - National Institute of Diabetes and Digestive and Kidney Diseases (2016). https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosis-diverticulitis/Pages/overview.aspx Accessed on July 28, 2016
- ↑ Diverticulitis entry at Merriam Webster's Medical dictionary
- ↑ Thompson WG, Patel DG (1986). "Clinical picture of diverticular disease of the colon". Clin Gastroenterol. 15 (4): 903–16. PMID 3536213.
- ↑ Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
- ↑ Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA (2010). "Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis". World J Surg. 34 (11): 2717–22. doi:10.1007/s00268-010-0726-7. PMID 20645093.
- ↑ Schreyer AG, Layer G, German Society of Digestive and Metabolic Diseases (DGVS) as well as the German Society of General and Visceral Surgery (DGAV) in collaboration with the German Radiology Society (DRG) (2015). "S2k Guidlines for Diverticular Disease and Diverticulitis: Diagnosis, Classification, and Therapy for the Radiologist". Rofo. 187 (8): 676–84. doi:10.1055/s-0034-1399526. PMID 26019048.
- ↑ Neff CC, vanSonnenberg E (1989). "CT of diverticulitis. Diagnosis and treatment". Radiol Clin North Am. 27 (4): 743–52. PMID 2657852.
- ↑ Ambrosetti P (2016). "Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography". Clin Exp Gastroenterol. 9: 249–57. doi:10.2147/CEG.S110428. PMC 4993273. PMID 27574459.
- ↑ Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP (2014). "Toward an evidence-based step-up approach in diagnosing diverticulitis". Scand J Gastroenterol. 49 (7): 775–84. doi:10.3109/00365521.2014.908475. PMID 24874087.
- ↑ Goh V, Halligan S, Taylor SA, Burling D, Bassett P, Bartram CI (2007). "Differentiation between diverticulitis and colorectal cancer: quantitative CT perfusion measurements versus morphologic criteria--initial experience". Radiology. 242 (2): 456–62. doi:10.1148/radiol.2422051670. PMID 17255417.
- ↑ Stollman NH, Raskin JB (1999). "Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology". Am J Gastroenterol. 94 (11): 3110–21. doi:10.1111/j.1572-0241.1999.01501.x. PMID 10566700.
- ↑ McKee RF, Deignan RW, Krukowski ZH (1993). "Radiological investigation in acute diverticulitis". Br J Surg. 80 (5): 560–5. PMID 8518890.