DIVERTICULITIS
I. Definition
A. Inflammation or localized perforation of diverticulum with abscess formation
B. Occurs annually in approximately 5% of patients with diverticulosis
II. Etiology
A. Not clearly proven
B. Low stool weight, leading to high colonic pressure
C. Low-fiber diet
D. Abnormal colonic motility, leading to increased colonic pressure
E. Weakness and defects in the colon wall
III. Clinical manifestations
A. Lower left quadrant pain (mild to moderate) and fever are the main clinical features.
B. Constipation is common and may alternate with diarrhea.
C. Fever and abdominal tenderness, guarding, palpable mass, spasms, and rebound tenderness indicate inflammation due to abscess.
D. Nausea and vomiting
E. Bowel sounds are usually hypoactive.
F. Abdominal distention and exaggerated bowel sounds if obstruction occurs
G. Dysuria and frequency may be present, owing to a colonic inflammatory process that causes irritation to the bladder.
V. Management
A. Patients with mild symptoms can be treated conservatively at home.
1. Rest the bowel.
a. Clear liquids; then, low residue for 24 to 48 hours
b. Progress to a high-fiber diet as normal bowel function returns.
2. Bed rest during acute phase
3. Antibiotic therapy may consist of the following:
a. Amoxicillin and clavulanate potassium (875 mg/125 mg) or metronidazole (Flagyl), 500 mg 3 times a day, plus
b. Ciprofloxacin (Cipro), 500 mg twice daily, or
c. Trimethoprim-sulfamethoxazole (Bactrim DS), 160/800 mg twice daily for 7 to 10 days, or until patient is afebrile for 3 to 5 days
4. Instruct patient to avoid laxatives and enemas.
B. More severe cases—Hospitalization is necessary.
1. NPO (nothing by mouth), NGT (nasogastric tube)
2. IV fluids
3. Antibiotics
a. Single-agent therapy with a second-generation cephalosporin (e.g., cefoxitin [Mefoxin], piperacillin-tazobactam [Zosyn], ticarcillin clavulate [Timentin]) appears to be as effective as combination therapy (e.g., metronidazole [Flagyl] or clindamycin [Cleocin] plus an aminoglycoside) or a third-generation cephalosporin (e.g., ceftazidime [Fortaz], cefotaxime [Claforan]).
b. Should be continued for 7 to 10 days and should be followed by colonoscopy or barium enema
c. Life-threatening case: Imipenem (Primaxin), 500 mg IV every 6 hours, or meropenem (Merrem) may be needed.
4. Morphine is contraindicated as an analgesic because it may increase colonic pressure. Pentazocine (Talwin) or meperidine (Demerol) is preferred.
5. Severe disease or failure to respond to treatment within 72 hours requires surgical consultation.
ULCERATIVE COLITIS
I. Definition
A. Inflammatory bowel disease of unknown etiology that is characterized by bouts of inflammation of a portion of or the entire colon
B. In most patients, the disease is intermittent, with episodes of flareup and remission.
II. Clinical manifestations
A. Bloody diarrhea is the cardinal sign.
B. Fever
C. Abdominal pain
D. Weight loss
E. Ask patient about stool frequency, rectal bleeding including amount, cramps, pain, fecal urgency, and tenesmus (spasmodic contraction of anal sphincter with pain and persistent desire to empty the bowel).
F. Extracolonic complications
1. Arthralgias and arthritis (15% to 20% of patients)
2. Ocular complications
3. Skin disorders
a. Erythema nodosum
b. Pyoderma gangrenosum
c. Mouth ulcers
4. Liver disorders
a. Cirrhosis
b. Fatty liver
c. Bile duct cancer
5. Spondylitis
6. Thromboembolic disease
G. Patient may exhibit signs and symptoms of hypovolemic shock in severe disease. Symptoms may range from mild to systemic toxicity, depending on the severity of the bleeding and of the inflammation.
H. Assessment of disease activity (Table 38-1)
| Mild | Moderate | Severe | |
|---|---|---|---|
| Albumin | Normal | 3 to 3.5 g/dl | Less than 3.0 g/dl |
| Erythrocyte sedimentation rate | Less than 20 mm/hour or normal | 20 to 30 mm/hour | More than 30 mm/hour |
| Heart rate (beats/minute) | Less than 90 | 90 to 100 | Higher than 100 |
| Hematocrit | Normal | 30 to 40 ml/dl | Less than 30 ml/dl |
| Stool, #/day | Fewer than four | Four to six | More than six (bloody) |
| Temperature | Normal | 99° F to 100° F | Above 100° F |
| Weight loss | None | 1% to 10% | Greater than 10% |
III. Laboratory/diagnostic findings
A. See Table 38-1.
B. Leukocytosis during inflammation
C. Anemia
D. Electrolyte abnormalities (hypokalemia)
E. Causes elevated values on liver function tests (if hepatobiliary disease is present)
F. Stool cultures for infectious disease are negative.
H. Plain abdominal x-rays exclude dilatation and are helpful in the determination of disease state (bowel containing feces is most likely not severely inflamed).
I. Barium enema is used less frequently.
J. Colonoscopy and barium enema should not be performed in an acute attack because these could cause exacerbation.
IV. Management
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A. Derivatives of 5-ASA (sulfasalazine, mesalamine, balsalazide) are currently available and result in symptomatic improvement in 50% to 75% of patients.
B. Sulfasalazine (Azulfidine) is the cornerstone of drug therapy for mild to moderate cases of ulcerative colitis, although it is associated with a greater number of adverse effects.
1. For active disease, 4 g per day; 2 g daily for maintaining remission
2. Should be initiated at 500 mg/day and increased every few days up to 4-6 g/day for the therapeutic dose
3. Patients with sulfa allergies should avoid this drug.
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