Signs and Symptoms
History
- Chronic or intermittent abdominal pain:
- Often precipitated by eating
- Sometimes relieved by flatulence or bowel movement
- Change in bowel pattern:
- Dyspepsia
- Painless hematochezia; 75% self-limiting:
- Left colon origin: Bright red
- Right 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 variable:
- Tenderness in left lower quadrant
- Firm sigmoid colon in left lower quadrant
- Rectal exam variable:
- Heme-negative stool
- Blood if diverticular bleed
Essential Workup
Thorough history and physical exam essential to avoid excessive workup
Diagnostic Tests & Interpretation
Lab
- Asymptomatic diverticulosis:
- Requires no workup, frequent incidental finding
- Recurrent symptomatic uncomplicated diverticular disease (SUDD):
- New onset SUDD:
- Requires workup to rule out carcinoma (if b-symptoms and /or heme-positive stool)
- CBC for leukocytosis or anemia
- Urinalysis to exclude hematuria or pyuria
- Hemorrhagic diverticulosis:
- CBC for hemoglobin
- Electrolytes, BUN, creatinine, glucose, calcium
- Type and cross for 4 units of packed RBCs
- PT, PTT, INR
- ECG
Imaging
- SUDD:
- CT of abdomen and pelvis or CT colonography:
- Stand ard for diagnosis in the emergency setting
- Excellent sensitivity and specificity
- Less evasive than colonoscopy or sigmoidoscopy
- Colonoscopy:
- Diverticulosis is most frequent incidental finding on routine studies
- Generally avoided if concerned for acute diverticulitis given risk of perforation
- Flexible sigmoidoscopy
- Hemorrhagic diverticulosis:
- Colonoscopy:
- Favored initial approach for diagnosis and treatment of diverticular bleeding
- Allows for direct visualization of bleeding
- Less successful for massive/rapid bleeding due to inability to visualize site of bleeding
- 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
- Traditional 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
- CT angiography:
- There may be a growing role for CT angiography especially if other imaging modalities are unavailable
- Can help guide surgical intervention should it be required
- Barium enema:
- Once the stand ard for diagnosis, now generally discouraged due to long exam time, risk of complications, and radiation exposure
Differential Diagnosis
- Painful diverticulosis:
- Irritable bowel syndrome (almost identical clinical presentation)
- Diverticulitis
- Colon carcinoma
- Crohn disease
- Urologic (renal colic)
- Gynecologic (ruptured or torsed ovarian cyst)
- Hemorrhagic diverticulosis:
- Hemorrhoids
- Anal fissure
- Proctitis
- Colitis
- Carcinoma
- Polyps
- Ischemic enteritis
- Angiodysplasia
- Amyloidosis
- Vascular-enteric fistula
- Upper GI source
Prehospital
- Avoid opiates in abdominal pain when underlying cause is uncertain
- Establish intravenous access
- For significant bleeding or hypotension:
- 1-2 L (20 mL/kg) bolus of crystalloid intravenous fluids
- Trendelenburg position
Initial Stabilization/Therapy
- Hemorrhagic diverticulosis (massive):
- Assess airway, breathing, and circulation
- Place two large-bore IVs or additional central venous catheter line access for high volume resuscitation
- If hypotensive, initial crystalloid fluid infusion is appropriate
- Consider administration of blood products via institutional massive transfusion protocol; ideally 1:1:1 ratio of PRCs:platelets:plasma
- Utilize O-negative blood (in females) and O-positive blood (in males) if type and cross in not yet available
- If patient is medically anticoagulated, may require appropriate reversal agent(s)
- Place nasogastric tube to rule out upper GI bleed if indicated
- Bladder catheter to monitor urine output
- Consult GI and surgery for persistent bleeding, impending hemorrhagic shock (most diverticular bleeding stops spontaneously)
ED Treatment/Procedures
- SUDD:
- High-fiber diet frequently recommended, with little high-quality evidence to support it
- Antispasmodics may have a role in a subset of patient with IBS and SUDD
- Mesalamine may control symptoms, but should be managed by GI specialist
- Probiotics can be considered to assist in GI motility and decreased intraluminal pressure
- Warm compresses to abdomen
- Reassurance
- Avoid cathartic laxatives
- 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
Medication
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 anticoagulation medications, aspirin, and NSAIDs
- No evidence for avoidance of nuts, corn, popcorn
- BoyntonW, FlochM. New strategies for the management of diverticular disease: insights for the clinician . Therap Adv Gastroenterol. 2013;6(3):205-213.
- CirocchiR, GrassiV, CavaliereD, et al. New trends in acute management of colonic diverticular bleeding: A systematic review . Medicine (Baltimore). 2015;94(44):e1710.
- FeuersteinJD, FalcukKR. Diverticulosis and diverticulitis . Mayo Clin Proc. 2016;91(8):1094-1104.
- ThompsonAE. Diverticulosis and diverticulitis . JAMA. 2016;316(10):1124.
- TursiA, PapaA, DaneseS. Review article: The pathophysiology and medical management of diverticulosis and diverticular disease of the colon . Aliment Pharmacol Ther. 2015;42(6):664-684.
- WilkinsT, BairdC, PearsonAN, et al. Diverticular bleeding . Am Fam Physician. 2009;80(9):977-983.
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