PANCE Blueprint GI and Nutrition (9%)

Diverticulitis will present as → a 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid-abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC.

Diverticulosis will present as → a 63-year-old male who is being evaluated in the emergency department for an episode of painless, bright red blood per rectum for two hours.

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Diverticulosis is defined as large outpouchings of the mucosa in the colon

• Presents with painless rectal bleeding, particularly in an elderly patient
• Seeds and nuts — Nut, corn, and popcorn consumption are not associated with an increase in risk of diverticulosis, diverticulitis or diverticular bleeding

Diverticulitis is defined as inflammation of the diverticula caused by obstructing matter

• Infection and macroperforation. Presents with constipation. LLQ pain, fever, ↑ WBC, ↑ CRP, and may bleed

Diagnose with a CT scan with oral and intravenous (IV) contrast

• CT will demonstrate fat stranding and bowel wall thickening.
• Occult blood in the stool and mild to moderate leukocytosis may occur with diverticulitis.
• Plain-film radiography should be done to rule out free air under the diaphragm indicative of a rupture.
• DO NOT perform a colonoscopy in an acute setting, as this can perforate the colon.

The outpatient treatment of acute colonic diverticulitis typically consists of pain control and a liquid diet without antibiotics

• Clinicians may choose to use antibiotics for outpatients who may be at higher risk for poor outcomes (comorbidities, immunocompromised, or signs of systemic disturbance)
• Limit patients to a liquid diet until they can be reassessed in two to three days, after which their diet can be liberalized to soft or regular if they demonstrate clinical improvement

"Seeds, corn, and nuts – Patients with diverticular disease have historically been advised to avoid consuming seeds, corn, and nuts out of concern that undigested fragments of such food items could become lodged within a diverticulum and incite diverticulitis. However, this theory is completely unproven. Thus, we do not counsel patients with a history of diverticulitis against consuming seeds, corn, and nuts."

• Hospitalization for IV administration of antibiotics, bowel rest, and analgesics is often required. A nasogastric tube is inserted if ileus develops.
• Surgical management may be necessary in severe cases, including peritonitis, large abscesses, fistulae, or obstruction.
• Patients with diverticulosis should maintain a high-fiber diet to prevent diverticulitis. Evidence has negated the need to recommend avoidance of nuts, seeds, and popcorn.