Diverticulosis
Background
Average inner diameters and ranges of different sections of the large intestine.[1]
- Outpouchings in colonic wall due to erosion of diverticular wall by inspissated fecal material, which can lead to microperforation
- If microperfs become infected/inflamed, can lead to diverticulitis
- Prevalence of diverticulosis 30% by age 60, >70% by age 85
- 70% of patients with diverticulosis remain asymptomatic
- Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Asia)
Clinical Features
- Typically asymptomatic OR
- Lower GI bleeding, painless
Differential Diagnosis
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Evaluation
- CBC
- Chemistries
- BUN may be elevated if bleeding occurs from site high in GI tract
- Coags
- LFTs
- Type and screen
- Fibrinogen
- ECG (if concern for silent ischemia in patients likely to have CAD)
- CTA
- Requires brisk bleeding rate (0.5 cc/min) for detection[citation needed]
- Tagged red blood cell scan
Management
- Categorize as stable versus unstable using shock index (HR/SBP), SI <1 stable, >1 unstable or suspect active bleeding
- Unstable patients resuscitate, CT angiogram, if CTA does not identify source of bleeding, upper endoscopy if hemodynamic instability [2]
- Stable calculate risk score
- Oakland score
- Glasgow-Blatchford score
- IVF
- Consider transfusing pRBCs/platelets for unstable patients or with very low hemoglobin (<7). with cardiovascular disease use trigger of 8 and target of 10 hemoglobin.
- Consider NGT - high possibility for surgery to request
- Emergent sigmoidoscopy/colonoscopy (next 24 hours)
- Surgery if endoscopy fails or not available
Major Bleed and Supratherapeutic INR
Disposition
- Depends on severity of bleeding
See Also
External Links
References
- ↑ Nguyen H, Loustaunau C, Facista A, Ramsey L, Hassounah N, Taylor H, et al. (July 2010). "Deficient Pms2, ERCC1, Ku86, CcOI in field defects during progression to colon cancer". Journal of Visualized Experiments (41). doi:10.3791/1931. PMC 3149991. PMID 20689513.
- ↑ Oakland K, Chadwick G, East JE, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;67:776-789.