Organ Systems: Gastrointestinal Disorders
Posted by admin on May 12th, 2010Other complications include fibrosis and bowel obstruction; fistula formation to the bladder (most common), vagina, or adjacent small intestine; perforation with peritonitis; and sepsis. Frank rectal bleeding is not characteristic of diverticulitis.
The clinical distinction between painful diverticular disease and diverticulitis carries a sizable rate of error. In an elderly or debilitated patient, the absence of fever, leukocytosis, or rebound tenderness does not exclude diverticulitis.
Bleeding associated with diverticula is usually brisk and painless. The origin of most diverticular bleeding, when known, is the right colon. Bleeding usually stops spontaneously, although 10% to 20% of patients have persistent hemorrhage. Bleeding results from rupture of the penetrating arteriole in its course around the diverticular sac.
Diagnosis .
Because diverticula are asymptomatic in most persons and are common in the elderly, other possible causes of nonspecific GI symptoms should be considered before attributing these symptoms to diverticula.
Other disorders that occur in the elderly may cause presenting symptoms similar to those of diverticular disease. For example, carcinoma of the colon, inflammatory bowel disease, and ischemia may mimic diverticulitis; a patient with vascular ectasias of the colon may present with brisk, painless bleeding.
If diverticulitis, abscess, or extraintestinal complications are suspected (eg, if a palpable mass is present), barium enema should usually be delayed about 1 wk to allow some resolution of the inflammatory process. A single contrast study should be done with precautions to minimize the risk of perforation and extravasation of contrast material. Computed tomography or ultrasonic imaging of the abdomen are safe studies that provide better definition of colonic wall thickness and ex-traluminal structures.
Colonoscopy is a less attractive option during an acute episode. It is best used to exclude tumors or other conditions when other diagnostic tests arc inconclusive. When contrast studies fail to identify the source of bleeding, colonoscopy is indicated. Before colonoscopy, colon cleansing is necessary; once the patient is stabilized and bleeding has slowed or stopped, balanced electrolyte solutions containing polyethylene glycol are given orally or by nasogastric lube. If bleeding remains brisk or the patient is unstable, selective mesenteric angiography can be used to locate the site of bleeding and to infuse vasoactive substances to control bleeding. If bleeding is intermittent or too slow to be detected by angiography, serial abdominal scans preceded by injection of technetium Tc 99m red blood cells can be used.
Tags: Disorders
