Diverticular Disease

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

This article have been viewed 1355 times

Chapter 19 Diverticular Disease

INTRODUCTION

Description: Diverticular disease involves herniation of the colon mucosa through the muscular wall. These herniations are most common in the sigmoid and distal colon, increase in prevalence with age, and can lead to significant morbidity when rupture or abscess formation occurs. Diverticulosis is the presence of these herniations, whereas diverticulitis is the symptomatic state.

Prevalence: Twenty percent of patients, increasing with age to 40% to 50% by age 60 to 80.

Predominant Age: Rare younger than age 40, most common in patients older than 50.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Speculative, not clearly established. Proposed—defect in colon motility with increased intraluminal pressure, exacerbated by a low-fiber diet or an intrinsic defect in the colon wall.

Risk Factors: Low-fiber diet, age older than 40, and previous diverticulitis.

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: Complete blood count, sedimentation rate, urinalysis with culture.

Imaging: Barium enema generally demonstrates diverticulosis. Supine and upright abdominal radiograph may demonstrate free air in the peritoneal cavity if rupture has occurred.

Special Tests: Colonoscopy or flexible sigmoidoscopy.

Diagnostic Procedures: History and physical examination, imaging or endoscopy.

Pathologic Findings

Herniation of colon mucosa through the muscularis, usually at the site of a perforating artery lying between two layers of serosa in the mesentery. Increased thickness of the muscular wall and narrowing of the gut lumen. With inflammation, necrosis and perforation occur.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: For diverticulosis—increased dietary fiber, stool softeners. Fiber supplements may be considered. For diverticulitis—evaluation, possible hospitalization (2% to 5% of patients).

Specific Measures: Patients with diverticulitis may become acutely ill with sepsis, toxicity, and peritonitis. These patients require hospitalization, fluid support, and aggressive antibiotic treatment. Surgical resection may be considered in patients with multiple attacks, fistulae, or abscesses that do not respond to medical therapy.

Diet: Increased dietary fiber is desirable both as prevention and to decrease the risk of complications in established disease. Patients who are acutely ill should receive nothing by mouth.

Activity: No restriction. Activity is encouraged to foster normal bowel function.

Patient Education: Reassurance, counseling regarding diet and the need for periodic flexible sigmoidoscopy or colonoscopy screening; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP151 (A Healthy Diet, For Women 65 and Older), AP120 (Problems of the Digestive System).

Drug(s) of Choice

Antispasmodics and adjuncts—hyoscyamine (Levsin) 0.125 mg PO one to two every 4 hours for 12/24 hours), buspirone (BuSpar) 15 to 30 mg PO daily.

Antibiotics (ambulatory)—metronidazole (Flagyl) 250 to 500 mg PO every 8 hours plus amoxicillin 500 mg PO every 8 hours or ciprofloxacin (Cipro) 500 mg PO two times daily.

Symptomatic control of diarrhea or constipation as needed.

Contraindications: See individual agents. Contraindications to flexible sigmoidoscopy: absolute—active diverticulitis, acute abdomen, blood dyscrasia, or coagulopathy, cardiopulmonary disease (acute or severe), inadequate bowel preparation, subacute bacterial endocarditis or prosthetic heart valve without adequate antibiotic prophylaxis, suspected bowel perforation; relative—active infection, peritonitis, pregnancy, recent abdominal surgery.

Precautions: If narcotic pain relievers are needed, meperidine (Demerol) is preferred; others should be avoided because they cause changes in bowel motility. Aminoglycosides may be associated with renal toxicity.

Interactions: See individual agents.

Alternative Drugs

Tobramycin may be used in combination with metronidazole.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Monitor for development of symptoms; perform routine flexible sigmoidoscopy and fecal occult blood screening.

Prevention/Avoidance: High-fiber diet and good bowel habits.

Possible Complications: Diverticulitis develops in 5% of patients with diverticulosis each year; lifetime risk is 50%. Enterocutaneous, enterovaginal, and perirectal fistulae may occur. Acutely, hemorrhage, perforation, abscess formation, peritonitis (with toxicity and collapse), and bowel obstruction may all occur.

Expected Outcome: With early detection and dietary change, the prognosis is good. With aggressive management of the first episode of diverticulitis, two thirds of patients do not have a recurrence. Up to 20% of those with rectal bleeding caused by diverticular disease have a recurrence of bleeding.

MISCELLANEOUS

Pregnancy Considerations: No direct effect on pregnancy, uncommon in reproductive-age women.

ICD-9-CM Codes: 562.10 (Diverticulosis of colon), 562.11 (Diverticulitis of colon).

Purkayastha S, Constantinides VA, Tekkis PP, et al. Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum. 2006;49:446.

Zarling EJ, Bernsen MB. The effect of gender on the rates of hospitalization for gastrointestinal illnesses. Am J Gastroenterol. 1997;92:621.

Bogardus STJr. What do we know about diverticular disease? A brief overview. J Clin Gastroenterol. 2006;40(7 Suppl 3):S108.

Di Mario F, Comparato G, Fanigliulo L, et al. Use of mesalazine in diverticular disease. J Clin Gastroenterol. 2006;40(7 Suppl 3):S155.

D’Souza AL. Ageing and the gut. Postgrad Med J. 2007;83:44.

Eglash A, Lane CH, Schneider DM. Clinical inquiries. What is the most beneficial diet for patients with diverticulosis? J Fam Pract. 2006;55:813.

Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol. 2006;12:3225.

Frattini J, Longo WE. Diagnosis and treatment of chronic and recurrent diverticulitis. J Clin Gastroenterol. 2006;40(7 Suppl 3):S145.

Frieri G, Pimpo MT, Scarpignato C. Management of colonic diverticular disease. Digestion. 2006;73(Suppl 1):58. Epub 2006 Feb 8.

Korzenik JR. Case closed? Diverticulitis: epidemiology and fiber. J Clin Gastroenterol. 2006;40(7 Suppl 3):S112.

Lundy JB, Edwards KD, Parker DM, Rivera DE. Recurrent rectal diverticulitis. Am Surg. 2006;72:633.

Naliboff JA, Longmire-Cook SJ. Diverticulitis mimicking a tuboovarian abscess. Report of a case in a young woman. J Reprod Med. 1996;41:921.

Salzman H, Lillie D. Diverticular disease: diagnosis and treatment. Am Fam Physician. 2005;72:1229.

Simpson J, Spiller R. Colonic diverticular disease. Clin Evid. 2005;14:543.

Tancer ML, Veridiano NP. Genital fistulas caused by diverticular disease of the sigmoid colon. Am J Obstet Gynecol. 1996;174:1547.

Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum. 1997;40:344.

Related

Netters Obstetrics and Gynecology