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 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

A Dutch research group created a clinical prediction rule for acute diverticulitis that includes three indicators: The presence of all three indicators had a specificity of 98% and a positive predictive value of 97%

The presence of all three of the following indicators is considered a positive result

  •  Absence of vomiting
  •  C-reactive protein level > 5 mg per dL (50 mg per L)
  •  Tenderness limited to the left lower quadrant

Diagnose with 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.
  • DO NOT perform a colonoscopy in an acute setting as this can perforate the colon

Diverticulitis with fat stranding ct scan copy

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.

osmosis Osmosis
Diverticulosis and diverticulitis assessment


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.

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Diverticulosis and diverticulitis interventions

When a patient is diagnosed with diverticular disease, diet, and lifestyle modifications must be made to prevent recurrence and/or exacerbations of the disease. Interventions include eating a diet high in fiber, taking products to soften the stool, reducing intra-abdominal pressure, and exercising. In severe instances, bowel resection may be necessary to remove the affected portion of the intestine.

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Question 1
Which of the following is not a known complication of diverticulitis?
See answer D for explanation
Colonic stricture
See answer D for explanation
See answer D for explanation
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?
Celiac disease
Symptoms usually occur following ingestion of gluten containing food. Also has extraintestinal manifestations.
Crohn disease
Abdominal pain commonly occurs at the right lower quadrant or periumbilical region. Also has extraintestinal manifestations.
Ulcerative colitis
Presents as bloody diarrhea. Also has extraintestinal manifestations.
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
Acute diverticulitis most commonly affects the ascending colon.
Patients with Ehlers-Danlos syndrome are disposed to development of diverticulosis.
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.
Diverticular disease is asymptomatic in 95% of cases.
See A for explanation.
Mild attacks can be treated on an outpatient basis using oral antibiotics such as ciprofloxacin and metronidazole.
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?
Barium enema
Barium enema is contraindicated during the initial stages of an acute attack because of the risk of free perforation.
Endoscopy is contraindicated during the initial stages of an acute attack because of the risk of free perforation.
CT scan
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?
Escherichia coli
Bacteroides fragilis
Streptococcus pneumoniae
a and b
Question 5 Explanation: 
The most common organisms involved in the development of diverticulitis are E. coli and B. fragilis.
There are 5 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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