PANCE Blueprint GI and Nutrition (9%)

Diverticular disease (Lecture)

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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What is the most common cause of lower GI bleed?
Diverticulosis

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

  • Presents with painless rectal bleeding, particularly in an elderly patient

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

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

Dignose with CT scan and no oral 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.
  • DO NOT perform colonoscopy in acute setting can perforate the colon

Diverticulitis with fat stranding ct scan copy

Low-residue diet and broad-spectrum antibiotics are appropriate for patients with mild diverticulitis.

"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.

IM_NUR_DiverticulosisAndDiverticuitisAssessment_v1.2_ A patient with diverticula, outpouchings found in the descending, sigmoid colon, is said to have diverticulosis. Diverticula are common in the older adult and may never produce symptoms or complications. However, when the outpouchings become inflamed, the condition is called diverticulitis. If left untreated, diverticulitis can lead to perforation of the intestine and can cause peritonitis. Clinical manifestations of diverticulitis include lower left-side abdominal pain, abdominal distention, flatulence, fever, rectal bleeding, and constipation or diarrhea.

Question 1
Which of the following is not a known complication of diverticulitis?
A
Fistula
Hint:
See answer D for explanation
B
Colonic stricture
Hint:
See answer D for explanation
C
Abscess
Hint:
See answer D for explanation
D
Colon cancer
Question 1 Explanation: 
Colon cancer is not a complication of diverticulitis. All other options are.
Question 2
A 79-year old woman presents with left lower quadrant abdominal pain with a history of changes in her elimination pattern. Physical examination reveals abdominal distention, tenderness and a palpable mass in the left lower quadrant. Barium enema shows segmental spasm and muscular thickening with a narrowed lumen. What is the most likely diagnosis?
A
Celiac disease
Hint:
Symptoms usually occur following ingestion of gluten containing food. Also has extraintestinal manifestations.
B
Crohn disease
Hint:
Abdominal pain commonly occurs at the right lower quadrant or periumbilical region. Also has extraintestinal manifestations.
C
Ulcerative colitis
Hint:
Presents as bloody diarrhea. Also has extraintestinal manifestations.
D
Diverticulitis
Question 2 Explanation: 
Diverticulitis presents commonly as left lower quadrant pain, tenderness, palpable mass, and abdominal distention.
Question 3
Which of the statements is false about diverticular disease
A
Acute diverticulitis most commonly affects the ascending colon.
B
Patients with Ehlers-Danlos syndrome are disposed to development of diverticulosis.
Hint:
A group of inherited disorders that mostly affect the skin, joints, and blood vessels. Patients with Ehlers-Danlos syndrome are disposed to development of diverticulosis.
C
Diverticular disease is asymptomatic in 95% of cases.
Hint:
See A for explanation.
D
Mild attacks can be treated on an outpatient basis using oral antibiotics such as ciprofloxacin and metronidazole.
Hint:
See A for explanation.
Question 3 Explanation: 
Acute diverticulitis most commonly affects the sigmoid (descending) colon. This may be a result of the relative high-pressure zone within the sigmoid colon.
Question 4
Which of the following imaging modalities is the best during an acute episode of diverticulitis?
A
Barium enema
Hint:
Barium enema is contraindicated during the initial stages of an acute attack because of the risk of free perforation.
B
Endoscopy
Hint:
Endoscopy is contraindicated during the initial stages of an acute attack because of the risk of free perforation.
C
CT scan
D
Ultrasound
Hint:
Ultrasound examination is often more readily available and is cheaper. It can demonstrate thickened bowel and large pericolic collections, but is less sensitive than CT.
Question 4 Explanation: 
CT scan is the best imaging modality during acute episode of diverticulitis. It can help in assessing disease severity, presence of complications, and clinical staging. Specificity and sensitivity, especially with helical CT and colonic contrast can be as high as 97%. Barium enema and endoscopy are contraindicated during the initial stages of an acute attack because of the risk of free perforation.
Question 5
Which of the following organisms is (are) most likely to be involved in the diverticulitis?
A
Escherichia coli
B
Bacteroides fragilis
C
Streptococcus pneumoniae
D
a and b
Question 5 Explanation: 
The most common organisms involved in the development of diverticulitis are E. coli and B. fragilis.
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