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  • • Results from perforation and/or infection of colonic diverticulum

    • Most common in sigmoid colon

    • Becomes clinically significant when infection spreads through wall of colon, into pericolic tissue

    • May lead to intra-abdominal abscess, peritonitis

    • Believed to result from increased intraluminal pressure

    • Cecal diverticulitis may resemble appendicitis clinically

    • May be complicated by colonic fistulae (colovesical, coloenteric)

    • Involvement of the entire colon in up to 10%

    Noncomplicated: Localized to colon, pericolic tissue

    Complicated: Abscess, fistula, obstruction, peritonitis

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Epidemiology

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  • • In western countries, diverticula develops in about 50% of persons (10% by age 40; 65% by age 80)

    • Dietary factors may contribute to formation of diverticula (low fiber)

    • Natural history of patients with diverticula: 10-25% become symptomatic

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Symptoms and Signs

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  • • May present with localized abdominal pain

    • Constipation or increased frequency of defecation

    • Dysuria with inflammatory process involving bladder

    • Nausea, vomiting

    • Fever

    • Abdominal distention

    • Pelvic or lower quadrant mass

    • Localized to diffuse peritonitis if freely perforated

    • May present as large bowel obstruction

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Laboratory Findings

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  • • Leukocytosis

    • Stool may be guaiac positive

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Imaging Findings

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  • Abdominal x-ray: May show free abdominal air if a diverticulum has freely perforated

    • Radiographic picture of ileus or bowel obstruction

    CT (oral and IV contrast)

    • -Effacement of pericolonic fat

      -Abscess

      -Fistula

      -Bowel wall thickening

    • Abscesses found on CT may be concomitantly percutaneously drained

    • Avoid colonoscopy (because of risk of perforation)

    Water soluble contrast enema: May reveal abscess, fistula, extrinsic compression by a paracolic mass

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  • • Colonic/visceral malignancy

    • Appendicitis

    • Renal colic

    • Other causes of bowel obstruction

    • -Stricture

      -Incarcerated hernia

      -Internal hernia

    • Crohn disease

    • Ulcerative colitis

    • Ischemic colitis

    • Antibiotic-associated colitis

    • Irritable bowel syndrome

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Rule Out

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  • • Colonic malignancy

    • Perforated carcinoma

    • Appendicitis

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  • • Plain x-ray to evaluate for free abdominal air

    • Contrast CT scan with percutaneous catheter drainage if abscess identified and accessible

    • Avoid colonoscopy or barium enema with acute presentation

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When to Admit

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  • • Signs of peritonitis or severe abdominal pain

    • Mild attacks (noncomplicated) without signs of peritonitis or other indicators of perforation or obstruction may be managed as outpatient

    • Signs of sepsis, obstruction, fistulas

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  • • Mild to moderate cases may be treated as outpatient with oral antibiotics

    • NPO, IV hydration

    • IV broad-spectrum antibiotics

    • Percutaneous drainage if abscess found on CT

    • NG decompression

    • Avoid opioid pain medications

    • May perform colonoscopy a week or so after acute process subsides

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Surgery

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Indications

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  • Emergency surgery

    • -Free perforation

      -Peritonitis

      -Massive bleeding

      -Complete obstruction

    Urgent surgery

    • -Failure of medical therapy

      -Immediate recurrence following resolution

      -Partial colonic ...

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