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Diverticulosis, Emergency Medicine

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

- Pseudodiverticula: - Outpouchings of mucosa and submucosa only - Most common form of colonic diverticula - True congenital diverticula (uncommon) contain all bowel wall layers.

- Complications - 70% are asymptomatic - 15-25% develop diverticulitis - 5-15% develop bleeding; obesity is a risk factor - Bleeding stops spontaneously in 75% of cases

- Chronic or intermittent abdominal pain - Often precipitated by eating - Sometimes relieved by flatulence or bowel movement

- Afebrile - Abdomen typically benign, but presentation variable - Tenderness in left lower quadrant - Firm sigmoid colon in left lower quadrant

- Hemorrhagic diverticulosis - CBC - Electrolytes, BUN, creatinine, glucose, calcium - Type and cross for 4 units of packed RBCs - PT, PTT, INR - ECG

- 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

- Hemorrhagic diverticulosis - Anoscopy - If mild bleeding, to rule out hemorrhoids - Massive bleeding from hemorrhoids is rare

- 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

- Painful diverticulosis - Irritable bowel syndrome (almost identical clinical presentation) - Diverticulitis - Colon carcinoma - Crohns disease - Urologic (renal colic) - Gynecologic (ruptured or torsed ovarian cyst)

- 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

- 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)

- 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

  • Single (diverticulum) or multiple (diverticula) colonic wall outpouchings from colonic muscle dysfunction, usually acquired
  • Sequence:Insufficient amounts of dietary fiber cause diminished stool bulkIncreased colonic contractions to propel stool through colon cause increase in intraluminal pressureIncreased 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 onlyMost common form of colonic diverticulaTrue congenital diverticula (uncommon) contain all bowel wall layers.
  • Common in Western society, owing to refined diet and low intake of fiber
  • Prevalence is age-dependent30% by 50 yr old, 65% by 85 yr old
  • Complications70% are asymptomatic15-25% develop diverticulitis5-15% develop bleeding; obesity is a risk factorBleeding stops spontaneously in 75% of casesInflammation (diverticulitis)Massive arterial bleeding usually from right colon:Fecalith (dry, hard stool) erodes through arterial branch.PerforationAbscessObstruction

Diagnosis

Signs and Symptoms

History

  • Chronic or intermittent abdominal painOften precipitated by eatingSometimes relieved by flatulence or bowel movement
  • Change in bowel pattern
  • Dyspepsia
  • Painless hematochezia; 75% self-limitingLeft colon origin: Bright redRight 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 variableTenderness in left lower quadrantFirm sigmoid colon in left lower quadrant
  • Rectal exam variableHeme-negative stoolBlood 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 diseaseRequires workup to rule out carcinoma (if weight loss, anorexia, heme-positive stool)CBC for leukocytosis or anemiaUrinalysis to exclude hematuria or pyuria
  • Hemorrhagic diverticulosisCBCElectrolytes, BUN, creatinine, glucose, calciumType and cross for 4 units of packed RBCsPT, PTT, INRECG

Imaging

  • Uncomplicated painful diverticulosis-outpatient optionsFlexible sigmoidoscopy, then barium enemaSigmoidoscopy: Rule out carcinoma (before barium studies for optimal visualization)Barium enema: Search for classic diverticula and exclude carcinoma or polypsColonoscopy
  • Hemorrhagic diverticulosisAnoscopyIf mild bleeding, to rule out hemorrhoidsMassive bleeding from hemorrhoids is rareProctosigmoidoscopyIf no blood in stool above rectum, assume rectal bleedColonoscopyCannot perform if bleeding excessive (difficult to visualize pathology)Allows for therapeutic interventionUsually done prior to radionuclide imaging or angiographyRadionuclide imagingSafe, no bowel prep neededPoor localization of bleeding siteIdeal for detecting intermittent bleeding, owing to long half-life of radioisotope (24-36 hr)No potential for therapeutic intervention, but helpful prior to angiographyAngiographyHelpful if bleeding site cannot be identified by colonoscopy; must be actively bleeding at least 0.5 mL/minLocalizes site of bleeding (more exact after radionuclide scanning)Allows for therapeutic interventionRisk of intestinal infarctionBarium enemaRarely indicated, but most sensitive for diagnosisIdentifies diverticula but not bleeding (can hinder visualization of other imaging techniques)

Differential Diagnosis

  • Painful diverticulosisIrritable bowel syndrome (almost identical clinical presentation)DiverticulitisColon carcinomaCrohns diseaseUrologic (renal colic)Gynecologic (ruptured or torsed ovarian cyst)
  • Hemorrhagic diverticulosisHemorrhoidsAnal fissureProctitisColitisCarcinomaPolypsIschemic enteritisAngiodysplasiaAmyloidosisVascular-enteric fistulaUpper 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 intravenouslyTrendelenburg 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 unstable0.9% NS bolus 1-2 L (20 mL/kg) for hypotensionCentral catheter placement if unstable following initial fluid resuscitation for more efficient delivery of fluids and monitoring of central venous pressureConsider nasogastric tube to rule out upper GI bleedBladder catheter to monitor urine outputTransfuse O-negative RBCs immediately if arrest is impendingConsult surgeon for persistent bleeding, impending hemorrhagic shock (most diverticular bleeding stops spontaneously)

Ed Treatment/Procedures

  • Uncomplicated symptomatic diverticulosisHigh-fiber diet and/or hydrophilic bulk laxative (i.e., psyllium)Warm compresses to abdomenReassuranceAvoid cathartic laxativesNo evidence to support use of antispasmodic (dicyclomine)
  • Hemorrhagic diverticulosis (massive):Initial stabilization (see above)Colonoscopy is diagnostic and potentially therapeuticRadionuclide scan; sensitive and noninvasive, but requires active bleedingSelective angiography with injection of vasopressin to control bleedingEmbolization, interventional radiology; consider before surgerySurgical 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)