Diverticulosis
Background
- 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 [1]
- 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
- ↑ 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.