eMedicine Specialties > Emergency Medicine > Gastrointestinal

Diverticular Disease: Follow-up

Author: Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Coauthor(s): Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Follow-up

Further Inpatient Care

  • Modalities used to stop bleeding include the following:
    • Intra-arterial vasopressin
    • Embolization was successful in 85% of cases based on a recent meta-analysis.
    • Endoscopic homeostasis by epinephrine injection, heater probe, or bipolar coagulation
  • If bleeding persists or clinical condition does not permit the above modalities, perform emergency surgery.

Further Outpatient Care

  • If the patient is not admitted and the diverticular disease episode resolves, arrange for colonoscopy and/or barium contrast enema.
  • Recommend a fiber-rich diet.

Transfer

  • Transfer patients if the medical center has no general surgeons or radiologic facilities.
  • Do not transfer patients with active GI bleeding and impending or actual peritonitis.

Deterrence/Prevention

  • High-fiber diet
  • Psyllium
  • Agar
  • Methylcellulose

Complications

  • Fistulas
    • Fistulas occur secondary to chronic diverticulitis or recurrent episodes of acute diverticulitis. Chronic inflammatory process causes adhesions to form between the colon and neighboring organs.
    • Colovesicular fistulas are the most common (most occur in men), followed by colovaginal fistulas (80% occur in women who have undergone hysterectomies). Additionally, fistulas to the integument, uterus, fallopian tubes, and pelvic floor have been reported.
    • Contrast enemas, retrograde dye studies, or CT scan confirms the diagnosis.
    • Treatment of fistulas consists of surgical resection of the involved colon.
  • Hemorrhage
  • Perforation with peritonitis
    • Clinical presentation typically is more severe than in acute diverticulitis.
    • It often is diagnosed by observing free air on plain radiographs. Barium enemas and endoscopy are contraindicated.
    • Treat surgically. Laparoscopic resection has comparable results to open resections when performed in experienced institutions.
  • Abscess
    • Suspect abscess when the patient fails to respond to medical therapy. It may be palpable.
    • CT scan or ultrasonography typically permits diagnosis of abscess.
    • Treat with percutaneous drainage. Some report successful transrectal and transvaginal drainage in selected situations.
  • Colonic obstruction
    • Colonic obstruction results from repetitive episodes of diverticulitis that cause mycosis coli or colonic muscular wall thickening.
    • Differentiate from other causes of obstruction, such as ischemia, colitis, or carcinoma, by contrast enemas or endoscopy.
    • If diagnosis is uncertain or obstructive symptoms develop, perform resection.

Prognosis

  • The Hinchey staging system reflects surgical outcome. It guides surgeons in selecting their operative strategy and reflects the risk of secondary complications after the acute episode is managed successfully.
    • Stage I - Pericolic abscess
    • Stage II - Pelvic abscess
    • Stage III - Purulent peritonitis
    • Stage IV - Feculent peritonitis
  • Stage I disease treated by primary resection has 0% mortality, while stages II and III have 5% and 18% mortality, respectively.
  • Prognosis is good with early detection and treatment of complications.
  • Of those with a first episode of diverticulitis who successfully are treated medically, 67% do not have subsequent attacks requiring hospitalization, and 33% have recurrences; 2-3 recurrences in 1-2 years is an indication to electively remove the involved segment of colon.
  • Of those with diverticular bleeding, as many as 20% rebleed within months to years.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to promptly initiate empiric antibiotic therapy with clinically evident diverticulitis
  • Failure to promptly diagnose visceral perforation or peritonitis
  • Failure to adequately treat patients younger than 40 years
  • Failure to appreciate that right lower quadrant pain in an elderly patient or a premenopausal woman may be caused by acute diverticulitis

Special Concerns

  • Hemorrhage secondary to diverticulosis in elderly persons carries a worse morbidity and mortality.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Ziad N Kazzi, MD, to the development and writing of this article.



More on Diverticular Disease

Overview: Diverticular Disease
Differential Diagnoses & Workup: Diverticular Disease
Treatment & Medication: Diverticular Disease
Follow-up: Diverticular Disease
Multimedia: Diverticular Disease
References
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Further Reading

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Keywords

diverticular disease, diverticulitis, acute diverticulitis, diverticulosis, lower gastrointestinal bleeding, lower GI bleeding, Meckel iliac diverticulum, congenital diverticula, peridiverticular inflammation, tenesmus, recurrent urinary tract infections, colovesicular fistulas, pneumaturia, feculent vaginal discharge, low-fiber diet, high fat diets, beefdiets, colonic segmentation, defects in colonic wall strength

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Contributor Information and Disclosures

Author

Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Bennett Goss, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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