A CLOSER LOOK AT DIVERTICULOSIS AND MESENTERIC ISCHEMIA
Clinical Findings of Diverticular Disease
Diverticular disease encompasses two primary conditions: diverticulosis and diverticulitis.
1. Diverticulosis
Diverticulosis is characterized by the presence of diverticula, which are small pouches that form in the wall of the colon, typically due to increased intraluminal pressure. Most patients with diverticulosis are asymptomatic; however, some may experience mild symptoms such as:
- Abdominal Pain: Often localized to the left lower quadrant.
- Bloating: A sensation of fullness or distension in the abdomen.
- Altered Bowel Habits: This may include constipation or diarrhea.
Physical examination findings in asymptomatic patients are usually unremarkable. However, in cases where symptoms are present, tenderness may be noted upon palpation of the abdomen.
2. Diverticulitis
Diverticulitis occurs when one or more diverticula become inflamed or infected. The clinical presentation is more pronounced and can include:
- Acute Abdominal Pain: Typically localized to the left lower quadrant but can be diffuse.
- Fever: Often low-grade but can be higher in severe cases.
- Nausea and Vomiting: Due to irritation of the gastrointestinal tract.
- Change in Bowel Habits: Patients may experience constipation or diarrhea.
On physical examination, signs may include:
- Tenderness: Localized to the left lower quadrant.
- Rebound Tenderness: Suggestive of peritoneal irritation if perforation has occurred.
- Guarding or Rigidity: Indicating possible complications such as abscess formation.
Complications of Diverticular Disease
Complications associated with diverticular disease include:
- Abscess Formation: Localized collections of pus that can occur due to inflammation. Treatment often involves antibiotics and possibly percutaneous drainage.
- Perforation: This can lead to peritonitis and requires surgical intervention, often necessitating resection of affected bowel segments.
- Fistula Formation: Abnormal connections between the colon and other organs (e.g., bladder). Surgical repair is typically required.
- Stricture Formation: Narrowing of the bowel lumen due to chronic inflammation, which may require surgical intervention if symptomatic.
Overview of Treatment for Complications:
- For uncomplicated diverticulitis, treatment typically involves:
- Antibiotics (e.g., ciprofloxacin and metronidazole).
- Dietary modifications (clear liquid diet initially).
- In cases of complicated diverticulitis (abscesses or perforation), surgical intervention may be necessary:
- Abscess drainage via percutaneous approach or surgery.
- Resection of affected bowel segment in case of perforation.
Clinical Findings and Presentation of Mesenteric Ischemia
Mesenteric ischemia occurs when blood flow to the intestines is reduced, leading to ischemia and potential necrosis. Clinical presentation includes:
- Acute abdominal pain: Sudden onset, often out of proportion to physical exam findings; patients may describe it as severe cramping.
- Nausea and vomiting: Commonly reported due to intestinal distress.
- Diarrhea or bloody stools: May occur as ischemia progresses.
Physical examination might reveal:
- Abdominal tenderness without guarding early on; however, as ischemia worsens, signs of peritonitis may develop.
Diagnosis: Diagnostic tests include:
- CT angiography: To visualize mesenteric vessels for occlusion or stenosis.
- MRI or ultrasound: May also be used but are less common than CT angiography.
Treatment: Management depends on severity:
- For acute mesenteric ischemia due to embolism/thrombosis: Surgical revascularization (embolectomy) is often required.
- Medical management includes anticoagulation therapy if indicated.
In other words, management includes restoring blood flow through surgical revascularization or endovascular techniques. In cases where bowel necrosis has occurred, resection of nonviable bowel is necessary.
Massive Lower GI Bleeding
Massive lower gastrointestinal bleeding is defined as significant blood loss from the gastrointestinal tract originating distal to the ligament of Treitz.
Differential Diagnosis: Common causes include:
- Diverticular bleeding
- Colorectal cancer
- Angiodysplasia
- Inflammatory bowel disease
Initial Management: Immediate management focuses on stabilization:
- Assess hemodynamic status (vital signs).
- Initiate IV fluid resuscitation and blood transfusions if necessary.
- Monitor hemoglobin levels closely.
Appropriate Diagnostic Tests: After stabilization:
- Colonoscopy is both diagnostic and therapeutic; it allows for direct visualization and potential intervention (e.g., cauterization).
- CT angiography can help identify sources of bleeding if colonoscopy fails.
Treatment: Management strategies depend on etiology:
- Endoscopic interventions for identifiable lesions during colonoscopy (e.g., clipping/diversion).
- Surgical intervention for persistent bleeding that cannot be controlled endoscopically or for malignancies identified during evaluation.