Abstract
Diverticulitis is a common cause of acute abdominal pain in western and industrialized countries. Found more commonly in women, the disease occurs more commonly after the forth decade. Diverticulitis occurs when small herniations of the colonic mucosa and submucosa, known as diverticula, become inflamed or tear. It is estimated that approximately 75% of patients will have diverticula by the age of 80, as there is age-related weakening of the abdominal wall in areas of insertion of the vasa recta. Decrease bowel motility of senescence may also play a role in increasing intracolonic pressure, as may changes in the microbiome of the gastrointestinal tract.
Patients with diverticulitis will develop abdominal pain that is usually located in the left lower quadrant, although there is an increased incidence of right-sided diverticular disease in Asians. Constipation is present approximately 50% of the time, with diarrhea occurring in 25% of patients suffering from acute diverticulitis. Abdominal tenderness is invariably present as are fever and chills. The pain of diverticulitis is proportional to the extent of inflammation, with the pain ranging from mild, intermittent pain to severe, unremitting pain with frank signs of peritonitis including rebound tenderness. Lower gastrointestinal bleed, which may be significant, may also be present.
Keywords
diverticulitis, diverticulosis, abdominal pain, constipation, left upper quadrant pain, diarrhea, pericolic abscess, phelgmon, fecal peritonitis, ischemic colitis, abdominal angina
ICD-10 CODE K57.32
Keywords
diverticulitis, diverticulosis, abdominal pain, constipation, left upper quadrant pain, diarrhea, pericolic abscess, phelgmon, fecal peritonitis, ischemic colitis, abdominal angina
ICD-10 CODE K57.32
The Clinical Syndrome
Diverticulitis is a common cause of acute abdominal pain in western and industrialized countries. Found more commonly in women, the disease occurs more commonly after the forth decade. Diverticulitis occurs when small herniations of the colonic mucosa and submucosa, known as diverticula, become inflamed or tear ( Fig. 78.1 ). It is estimated that approximately 75% of patients will have diverticula by the age of 80, as there is age-related weakening of the abdominal wall in areas of insertion of the vasa recta. Decrease bowel motility of senescence may also play a role in increasing intracolonic pressure, as may changes in the microbiome of the gastrointestinal tract.
Patients with diverticulitis will develop abdominal pain that is usually located in the left lower quadrant, although there is an increased incidence of right-sided diverticular disease in Asians ( Fig. 78.2 ). Constipation is present approximately 50% of the time, with diarrhea occurring in 25% of patients suffering from acute diverticulitis. Abdominal tenderness is invariably present as are fever and chills. The pain of diverticulitis is proportional to the extent of inflammation, with the pain ranging from mild, intermittent pain to severe, unremitting pain with frank signs of peritonitis including rebound tenderness. Lower gastrointestinal bleed, which may be significant, may also be present.
Factors that increase the risk of developing diverticulitis include advancing age, low-fiber high-fat diet, obesity, smoking, and the use of corticosteroids and nonsteroidal antiinflammatory agents. Diets high in vitamin D and the use of statins and calcium channel blocker may exert a protective effect. Mild cases of diverticulitis are managed conservatively, but approximately 25% of patients with acute diverticulitis will develop complications that may include abscess formation, bowel obstruction, peritonitis, and sepsis.
Signs and Symptoms
Left-sided abdominal pain is present in most patients with acute diverticulitis, although patients of Asian descent have an increased incidence of right-sided diverticulitis, which may mimic acute appendicitis. The pain of acute diverticulitis is associated with anorexia and a change in bowel habits and gastrointestinal symptoms of constipation, diarrhea, bloating, flatulence, and nausea and vomiting. A small percentage of patients will complain of urinary urgency and frequency secondary to irritation of the adjacent urinary tract. Often the patient will flex the hip on the affected side owing to irritation of the psoas muscle. Mild diverticulitis may produce minimal constitutional symptoms, but if the disease progresses, fever and chills may be pronounced.
On physical examination, the extent of abdominal findings will be in proportion to the extent of the diverticulitis. Small microperforations of left-sided diverticula will produce diffuse left lower quadrant pain with minimal peritoneal findings. With more severe diverticulitis, the pain will become more localized to the left lower quadrant and pelvis with rebound tenderness a prominent physical findings. If a peridiverticular abscess or phlegmon forms, a tender, palpable mass may be identified. The abdomen may be distended and tympanic to percussion, with bowel sounds diminished or absent. If a fistula into the genitourinary tract forms, fecaluria or pneumaturia may be present with colovaginal fistulas occurring in females ( Fig. 78.3 ).
