Clinical Approach 1
Diverticulosis is extremely common, affecting 50-80% of people older than 80 years. Diverticula are, in fact. /j.ve//i/«diverticula through a weakness in the muscle lining, typically at areas of vascular penetration to the smooth muscle. Therefore, their walls do not contain the muscle layers surrounding the colon. They are typically 5-10 mm in diameter and occur mainly in the distal colon in western societies. The development of diverticula has been linked to insufficient dietary fiber leading to alteration in colonic transit time and increased resting colonic intraluminal pressure. The majority of patients will remain asymptomatic. However, some patients will have chronic symptoms resembling those of irritable bowel syndrome (nonspecific lower abdominal pain aggravated by eating with relief upon defecation, bloating, and constipation or diarrhea). They may even present with acute symptoms that could be confused with acute diverticulitis, but without evidence of inflammation upon further workup. This entity has been named "painful diverticular disease without diverticulitis." Complications of diverticulosis include acute diverticulitis, hemorrhage, and obstruction.
Diverticular hemorrhage, one of the most common causes of lower GI bleeding in patients older than 40 years, typically presents as painless passage of bright red blood. Generally, the hemorrhage is abrupt in onset and abrupt in resolution. The diagnosis may be established by finding diverticula on endoscopy without other pathology. Most diverticular hemorrhages are self-limited, and treatment is supportive, with intravenous fluid or blood replacement as needed. Treatment of diverticulosis consists of dietary measures with increased fiber. Avoidance of foods with small seeds (e.g., strawberries) is traditionally advised, although data supporting this recommendation are scant. For patients with recurrent or chronic bleeding, resection of the affected colonic segment may be indicated.
Acute diverticulitis is the most common complication of diverticulosis, developing in approximately 20% of all patients with diverticula. Patients often present with acute abdominal pain and signs of peritoneal irritation localizing to the left lower quadrant and often thought of presenting like "left-sided appendicitis." Inspissated stool particles (fecaliths) appear to obstruct the
Table 26-1
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