QUICK RECERTIFICATION SERIES
Diverticular disease
Johanna L. Chelcun, MHS, PA-C; Thomas D’Addario, MSW
GENERAL FEATURES
• Colonic diverticular disease is a condition in which
intestinal mucosal layers protrude through a defect in
the smooth muscle layer.
{ Results from increased pressure within the bowel
{ Associated with low-fiber diet, chronic constipation,
and obesity
{ More common with older age but incidence has
increased in younger population in recent years
• Diverticular bleeding occurs from vasa recta arteries at
the weak point where they penetrate the bowel wall.
{ Most common cause of hematochezia
• Diverticulosis commonly occurs in the sigmoid colon
due to its decreased diameter and higher intraluminal
pressure; however, more than half of diverticular bleeds
occur in the ascending colon.
• Diverticulitis is localized inflammation of a diverticulum.
{ Increased pressure or luminal obstruction leads to
distension, ischemia, and microperforation of tissue.
{ Occurs in 10% of patients with diverticulosis
{ Can progress to macroperforation, abscess, fistulae,
and peritonitis
{ Multiple episodes may lead to colonic scarring and
strictures.
CLINICAL ASSESSMENT
• Diverticulosis itself is asymptomatic.
• Diverticular bleeding presents with painless hematoche-
zia, bloating, cramping, or urge to defecate.
• Diverticulitis presents with fever and cramping abdom-
inal pain, usually of the left lower quadrant.
{ Diarrhea, constipation, nausea, or vomiting may occur.
{ If right-sided, diverticulitis can mimic signs and symp-
toms of acute appendicitis.
{ Abdominal examination may reveal normal or decreased
bowel sounds, distension, or tenderness.
{ Guarding and rebound tenderness are signs of acute
peritonitis.
Johanna L. Chelcun is a clinical assistant professor at Quinnipiac
University in Hamden, Conn., and practices at Yale-New Haven Hospital
in New Haven, Conn. Thomas D’Addario is a student in the school of
medicine at the University of Connecticut in Farmington. The authors
have disclosed no potential conflicts of interest, financial or otherwise.
Dawn Colomb-Lippa, MHS, PA-C, department editor
DOI: 10.1097/01.JAA.0000456580.39509.e3
Copyright © 2014 American Academy of Physician Assistants
44 www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
DIAGNOSIS
• Laboratory studies are nonspecific; leukocytosis with
left shift may indicate diverticulitis but is not always
present.
• Colonoscopy is used to diagnose diverticulosis and
diverticular bleeding, but should not be performed when
diverticulitis is suspected due to risk of perforation.
• In patients with gastrointestinal bleeding of unknown
source, tagged red blood cell scan or CT angiography
may reveal source of bleeding.
• CT scan is the imaging method of choice for acute
diverticulitis.
{ CT findings include presence of diverticuli, colonic
wall thickening, and pericolic soft tissue changes.
{ Complications visible on CT include abscesses, fistulae,
bowel obstruction, or signs of perforation (free air).
• Abdominal flat plate can also be used to evaluate for
bowel obstruction or perforation.
QUESTIONS
1. A 76-year-old man presents with a 2-day history of
intermittent left lower quadrant abdominal pain. Which
feature from the patient’s history, physical, and laboratory
evaluation is most suggestive of colonic perforation?
a. hematochezia
b. rebound tenderness
c. fever
d. leukocytosis
2. A 60-year-old woman presents to the ED with abdominal
pain and reports a history of intermittent hematochezia.
Because she has a history of hemorrhoids, she has
not sought medical advice until now. Her vital signs
are BP, 118/86 mm Hg; pulse, 90 beats/minute;
and temperature, 101.8° F (38.8° C). An abdominal
examination reveals hypoactive bowel sounds,
distension, and mild tenderness. She has no guarding
or rebound tenderness. Laboratory studies reveal
leukocytosis. Which is the most appropriate next step?
a. IV ceftriaxone
b. CT scan of the abdomen
c. emergent surgery
d. colonoscopy
Volume 27 • Number 12 • December 2014
 Diverticular disease

TREATMENT { Patients with recurrent episodes of diverticulitis may

• Increasing dietary fiber may reduce incidence of disease,
but may not reduce symptoms in presence of diverticu-
lar disease.
• Diverticular bleeding is usually self-limited; may require
localized therapy or surgical intervention.
{ Endoscopic treatment options include epinephrine
injection, clipping, or band ligation.
{ Intra-arterial vasopressin may be infused during
angiography.
{ Blood transfusion may be needed if significant hemor-
rhage occurs.
• Treatment of diverticulitis includes bowel rest, hydration,
and oral or IV antibiotics.
{ New evidence suggests that in certain cases of uncom-
plicated diverticulitis, antibiotic therapy may not
change patient outcomes, and patients may be managed
conservatively.
{ Percutaneous drainage or surgical intervention is indicated
in patients with abscess formation or peritonitis.
need elective surgical resection of the affected area.
diverticulitis.
colonoscopy is not done in patients with suspected
would be premature. Because of the risk of perforation,
rebound tenderness or guarding, and emergent surgery
concerns in patients with diverticulitis, this patient has no
of diverticulitis. Although perforation and peritonitis are
inflammation. Antibiotics are indicated in most cases
which would show evidence of diverticular disease and
appropriate test would be a CT scan of the abdomen,
2. B. The patient has signs of diverticulitis. The most
occur in uncomplicated diverticulitis.
with diverticular bleeding; fever and leukocytosis can
caused by bowel perforation. Hematochezia is associated
1. B. Rebound tenderness raises concern for peritonitis
Answers

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