Basics
Description
- Single (diverticulum) or multiple (diverticula) colonic wall outpouchings from colonic muscle dysfunction, usually acquired
- Sequence:
- Insufficient amounts of dietary fiber cause diminished stool bulk
- Increased colonic contractions to propel stool through colon cause increase in intraluminal pressure
- Increased pressure forces mucosa and submucosa to herniate through muscularis propria at its weakest point, where vasa recta penetrate
Etiology
- Occurs anywhere in GI tract, although generally a colonic disease:
- Left sided 95% (Western countries)
- Right sided 70% (Asian countries)
- Sigmoid colon most common site
- Pseudodiverticula:
- Outpouchings of mucosa and submucosa only
- Most common form of colonic diverticula
- True congenital diverticula (uncommon) contain all bowel wall layers.
- Common in Western society, owing to refined diet and low intake of fiber
- Prevalence is age-dependent
- 30% by 50 yr old, 65% by 85 yr old
- Complications
- 70% are asymptomatic
- 15-25% develop diverticulitis
- 5-15% develop bleeding; obesity is a risk factor
- Bleeding stops spontaneously in 75% of cases
- Inflammation (diverticulitis)
- Massive arterial bleeding usually from right colon:
- Fecalith (dry, hard stool) erodes through arterial branch.
- Perforation
- Abscess
- Obstruction
Diagnosis
Signs and Symptoms
History
- Chronic or intermittent abdominal pain
- Often precipitated by eating
- Sometimes relieved by flatulence or bowel movement
- Change in bowel pattern
- Dyspepsia
- Painless hematochezia; 75% self-limiting
- Left colon origin: Bright red
- Right colon origin: Dark or maroon colored, mixed with stool
- Diverticulitis and diverticular bleeding are separate entities and rarely coexist.
Physical Exam
- Afebrile
- Abdomen typically benign, but presentation variable
- Tenderness in left lower quadrant
- Firm sigmoid colon in left lower quadrant
- Rectal exam variable
- Heme-negative stool
- Blood if diverticular bleed
Essential Workup
Thorough history and physical exam essential to avoid excessive workup
Diagnosis Tests & Interpretation
Lab
- Asymptomatic diverticulosis
- Recurrent uncomplicated painful disease
- New onset uncomplicated painful disease
- Requires workup to rule out carcinoma (if weight loss, anorexia, heme-positive stool)
- CBC for leukocytosis or anemia
- Urinalysis to exclude hematuria or pyuria
- Hemorrhagic diverticulosis
- CBC
- Electrolytes, BUN, creatinine, glucose, calcium
- Type and cross for 4 units of packed RBCs
- PT, PTT, INR
- ECG
Imaging
- Uncomplicated painful diverticulosis-outpatient options
- Flexible sigmoidoscopy, then barium enema
- Sigmoidoscopy: Rule out carcinoma (before barium studies for optimal visualization)
- Barium enema: Search for classic diverticula and exclude carcinoma or polyps
- Colonoscopy
- Hemorrhagic diverticulosis
- Anoscopy
- If mild bleeding, to rule out hemorrhoids
- Massive bleeding from hemorrhoids is rare
- Proctosigmoidoscopy
- If no blood in stool above rectum, assume rectal bleed
- Colonoscopy
- Cannot perform if bleeding excessive (difficult to visualize pathology)
- Allows for therapeutic intervention
- Usually done prior to radionuclide imaging or angiography
- Radionuclide imaging
- Safe, no bowel prep needed
- Poor localization of bleeding site
- Ideal for detecting intermittent bleeding, owing to long half-life of radioisotope (24-36 hr)
- No potential for therapeutic intervention, but helpful prior to angiography
- Angiography
- Helpful if bleeding site cannot be identified by colonoscopy; must be actively bleeding at least 0.5 mL/min
- Localizes site of bleeding (more exact after radionuclide scanning)
- Allows for therapeutic intervention
- Risk of intestinal infarction
- Barium enema
- Rarely indicated, but most sensitive for diagnosis
- Identifies diverticula but not bleeding (can hinder visualization of other imaging techniques)
Differential Diagnosis
- Painful diverticulosis
- Irritable bowel syndrome (almost identical clinical presentation)
- Diverticulitis
- Colon carcinoma
- Crohns disease
- Urologic (renal colic)
- Gynecologic (ruptured or torsed ovarian cyst)
- Hemorrhagic diverticulosis
- Hemorrhoids
- Anal fissure
- Proctitis
- Colitis
- Carcinoma
- Polyps
- Ischemic enteritis
- Angiodysplasia
- Amyloidosis
- Vascular-enteric fistula
- Upper GI source
Treatment
Pre-Hospital
- Avoid opiates in abdominal pain when underlying cause is uncertain.
- Establish 2 large-bore IV lines
- For significant bleeding or hypotension:
- 1-2 L (20 mL/kg) bolus 0.9% NS intravenously
- Trendelenburg position
Initial Stabilization/Therapy
- Hemorrhagic diverticulosis (massive):
- Airway control (100% O2 or intubate if unresponsive)
- Intravenous access with at least 1 large-bore catheter or 2 if unstable
- 0.9% NS bolus 1-2 L (20 mL/kg) for hypotension
- Central catheter placement if unstable following initial fluid resuscitation for more efficient delivery of fluids and monitoring of central venous pressure
- Consider nasogastric tube to rule out upper GI bleed
- Bladder catheter to monitor urine output
- Transfuse O-negative RBCs immediately if arrest is impending
- Consult surgeon for persistent bleeding, impending hemorrhagic shock (most diverticular bleeding stops spontaneously)
Ed Treatment/Procedures
- Uncomplicated symptomatic diverticulosis
- High-fiber diet and/or hydrophilic bulk laxative (i.e., psyllium)
- Warm compresses to abdomen
- Reassurance
- Avoid cathartic laxatives
- No evidence to support use of antispasmodic (dicyclomine)
- Hemorrhagic diverticulosis (massive):
- Initial stabilization (see above)
- Colonoscopy is diagnostic and potentially therapeutic
- Radionuclide scan; sensitive and noninvasive, but requires active bleeding
- Selective angiography with injection of vasopressin to control bleeding
- Embolization, interventional radiology; consider before surgery
- Surgical intervention for segmental colectomy
Medication
- Dicyclomine: 20 mg PO/IM QID (not for IV use)
- Propantheline: 15 mg PO 30 min ac/qhs
Follow-Up
Disposition
Admission Criteria
- ICU if unstable with massive hemorrhagic diverticulosis
- Mild or intermittent hemorrhagic diverticulosis that is otherwise stable so as to determine site of bleeding and evaluate need for definitive treatment
Discharge Criteria
- Uncomplicated, symptomatic diverticulosis
- Stable with trace heme-positive stool, negative gastric aspirate, no anemia, and no other complaints
Issues for Referral
GI follow-up for colonoscopy
Follow-Up Recommendations
- Colonoscopy within 48 hr of initial presentation for stable patients
- Discontinue aspirin and NSAIDs
- Increase intake of dietary fiber
- No evidence for avoidance of nuts, corn, popcorn
Pearls and Pitfalls
- 15% with hematochezia have an upper GI source
- Most cases (75-95%) resolve spontaneously or with conservative management
- Massive blood loss seen in 9-19% of patients, especially those with comorbid diseases or advanced age
- Colonoscopy is the initial diagnostic procedure of choice in stable patients
Additional Reading
- Bono MJ. Lower gastrointestinal tract bleeding. Emerg Med Clin North Am. 1996;14(3):547-556.
- K ¶hler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: Results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc. 1999;13(4):430-436.
- McGuire HH Jr. Bleeding colonic diverticula: A reappraisal of natural history and management. Ann Surg. 1994;220(5):653-656.
- Strate LL, Liu YL, Aldoori WH, et al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009;136:115-122.
- Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am. 2009;38(3):513-525.
- Wilkins T, Baird C, Pearson AN, et al. Diverticular bleeding. Am Fam Physician. 2009;80(9):977-983.
See Also (Topic, Algorithm, Electronic Media Element)
- Diverticulitis
- GI Bleeding
Codes
ICD9
- 562.10 Diverticulosis of colon (without mention of hemorrhage)
- 562.12 Diverticulosis of colon with hemorrhage
- 751.5 Other anomalies of intestine
ICD10
- K57.30 Dvrtclos of lg int w/o perforation or abscess w/o bleeding
- K57.31 Dvrtclos of lg int w/o perforation or abscess w bleeding
- Q43.8 Other specified congenital malformations of intestine
SNOMED
- 398157006 Diverticular disease of large intestine
- 398050005 diverticular disease of colon (disorder)
- 429430001 Diverticulosis of sigmoid colon (disorder)
- 253792003 Congenital diverticulosis (disorder)