DIVERTICULAR DISEASE

Herniations or saclike protrusions of the mucosa through the muscularis at points of nutrient artery penetration; possibly due to increased intraluminal pressure, low-fiber diet; most common in sigmoid colon.

CLINICAL PRESENTATION

  1. Asymptomatic (detected by barium enema or colonoscopy).
  2. Pain: recurrent left lower quadrant pain relieved by defecation; alternating constipation and diarrhea. Diagnosis by barium enema.
  3. Diverticulitis: pain, fever, altered bowel habits, tender colon, leukocytosis. Best confirmed and staged by CT after opacification of bowel. (In pts who recover with medical therapy, perform elective barium enema or colonoscopy in 4–6 weeks to exclude cancer.) Complications: pericolic abscess, perforation, fistula (to bladder, vagina, skin, soft tissue), liver abscess, stricture. Frequently require surgery or, for abscesses, percutaneous drainage.
  4. Hemorrhage: usually in absence of diverticulitis, often from ascending colon and self-limited. If persistent, manage with mesenteric arteriography and intra-arterial infusion of vasopressin, or surgery (Chap. 43: Gastrointestinal Bleeding).

Treatment: Diverticular Disease

PAIN

High-fiber diet, psyllium extract (e.g., Metamucil 1 tbsp PO qd or bid), anticholinergics (e.g., dicyclomine HCl 10–40 mg PO qid).

DIVERTICULITIS

NPO, IV fluids, antibiotics for 7–10 d (e.g., trimethoprim/sulfamethoxazole or ciprofloxacin and metronidazole; add ampicillin to cover enterococci in nonresponders); for ambulatory pts, ampicillin/clavulanate (clear liquid diet); surgical resection in refractory or frequently recurrent cases, young persons (age <50), immunosuppressed pts, or when there is inability to exclude cancer.

Pts who have had at least two documented episodes and those who respond slowly to medical therapy should be offered surgical options to achieve removal of the diseased colonic segment, controlling sepsis, eliminating obstructions or fistulas, and restoring intestinal continuity.

Outline

DIVERTICULAR DISEASEis the Harrison's Manual of Medicine Word of the day!