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GI: Diverticulitis
GI: Diverticulitis
47
Anatomy
Graduate
01/27/2012

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Term
intial imaging study of choice with diverticulitis:
Definition
CT of abdomen
Term
when should colonscopy be done with diverticulitis?
Definition
- NOT during acute flare
- wait for 6 weeks and then do one to rule out cancer and IBD
Term
Typical findings on abdominal CT with diverticulitis:
Definition
- thickening of bweol wall
- fistulas
- abscess
Term
Eval of diverticulitis bleeding:
Definition
- if greater than 1 mL/min> ARTERIOGRAPHY- can infuse vasopressin to arteries causing bleed and do selective arterial emobolization, but its expenseive and invasive)
Term
Non-pharmacologic treatment of diverticulitis:
Definition
- increase fiber intake and exercise
Term
Severe diverticulitis tmt:
Definition
- nothing by mouth
- IV hydration
- NG suction if ileus or small bowel obstruction is present
Term
Treatment for mild diverticulitis:
Definition
- liquid diet 7-10 days
- Ciprofloxacin 500 mg bid + Metronidazole 500 mg q6h

(cipro for aerobes, metro for anaerobes)these are considered broad spectrum
Term
Severe Diverticulitis tmt:
Definition
- NPO and IV antibiotics:
- Ampicillin-sulbactam
- Piperacillin-tazobactam
- Ciprofloxacin and Metronidazole
- Cefoxitine and Metronidazole
Term
Life threatening diverticulitis tmt:
Definition
- Imipenem 500 mg IV q6h
- Meropenum 1g IV q8h
Term
Surgery for diverticulitis should be considered when:
Definition
- Repeated episodes of diverticulitis (2 or more)
- Failure to respond to conservative management
- Abscess/fistula formation
- Obstruction
- Peritonitis
- Immunocompromised pts
- First episode in young pt less than 40 y/o
- Inability to rule out carcinoma
Term
Percentage of patients with diverticulitis that eventually require surgery?
Definition
30%
Term
An intra-abdominal abscess is a localized collection of pus confined in the __ __ by an __ __.
Definition
- peritoneal cavity
- inflammatory barrier
Term
Origin of intra-abdominal abscess:
Definition
- from bacteria that colonize the intestines- usually mix of aerobe and anaerobes

ANTIBIOTICS NOT EFFECTIVE B/C THE ABSCESS IS NOT VASCULARIZED
Term
Causes of Intra-abdominal abscesses:
Definition
- Perforation of viscus
- Perforation of peptic ulcers
- Peforated appendicitis and diverticulitis
- Gangrenous cholecystitis
- Mesenteric ischemia with bowel infarction
- Pancreatitis or pancreatic necrosis progressing to pancreatic abscess
- Blunt trauma
Term
Risk factors for intra-abdominal abscess formation:
Definition
- Pre-existing organ dysfunction
- Underlying malignancy
- Transfusion
- Chronic steroid use
- Increasing age
- Malnutrition
Term
Intra-abdominal abscess presentation suggestive symptoms:
Definition
- persistant abdominal pain
- focal tenderness
- spiking fever
- persistent tachycardia
- prolonged ileus
- leukocytosis
- intermittent polymicrobial bacteremia
Term
Possibly the only initial clues of intraabdominal abscess:
Definition
- peristent fever
- mild liver dysfunction
- persistent GI dysfucntion
- nonlocalizing debilitating illness
Term
Blood cultures indicating persistent polymicrobiral bacteremia strongly implicate the presence of:
Definition
- intra-abdominal abscess
Term
More than 90% of intra-abdominal abscesses contain ___ organisms, particularly __ ___.
Definition
- anaerobic
- B. fragilis
Term
Post-operative ___ species bacteremia strongly suggests __ __.
Definition
- Bacteroides
- intraabdominal sepsis
Term
X-rays are not diagnostic of abscesses, but may indicate need for further work up. What are some findings tha may make you want to investigate possiblity of absces on x-ray:
Definition
- localized ileus
- extaluminal gas
- air-fluid levels
- mottled-soft tissue masses
- absence of psoas outlines
- displacement of viscera

chest radiograps with subphrenic or subhepatic abscess:
- pleural effusion
- elevated hemidiaphragm
- basilar infiltrates
- atelectasis
Term
Best test for imaging of intra-abdomminal abscess:
Definition
CT with IV and oral contrast
Term
choices for draining intra-abdominal abcess:
Definition
- First choice: percutaneous CT guided catheter drainage
- Surgical (laparoscopic or open) drainage
Term
Palpable tender, fluctuant mass impinging on the vagina or rectum:
Definition
- pelvic abscess
- best to drain transvaginally or transrectally
Term
Blind fistulas:
Definition
- open on one end only
Term
Complete fistulas:
Definition
- one internal opening
- one opening on the skin
Term
Incomplete fistulas:
Definition
- tubes of skin that are open on the outside but closed on the inside and do not connect to any internal structure
Term
Horseshoe fistulas:
Definition
- complex fistulas with more than one opening on the exterior of the body
Term
explain etiology os anal fistula:
Definition
anal gland inflammation> inflammation moves into muscle> abscess forms> half the time abscess becomes fistula
Term
SI and LI fistulas are associated with:
Definition
IBD
Term
__% of gastric fistulas are iatrogenic>
Definition
85%
Term
80% of SI fistulas are from __ __.
Definition
abdominal surgeries
Term
Colonic fistulas mostly come from __ __ but can also occur after surgery for an inflammatory condition.
Definition
intra-abdominal inflammation
Term
Risk Factors for Fistula formation:
Definition
- Malignancy (especially gynecological or pancreatic)
- Radiation
- IBD
- Diverticular Diseases
- Appendicitis
- Perforation of abdominal ulcer
- Surgery for cancer, IBD, adhesions, or PUD
- Aortic aneurysm
- Infected aortic graft
- Previous abdominal aortic surgery
- Abdominal trauma (gunshot, stab, MVA)
Term
Symptoms of gastrocolic fistula:
Definition
- abdominal pain
- weight loss
- feculent belching
Term
Enterovesical and Colovesical fistula symptoms:
Definition
- pneumaturia (air in urine stream)
- fecaluria (stool in urine stream)
- recurrent UTIs
Term
Rectovaginal or Anovaginal fistula symptoms:
Definition
- may be asymptomatic or only have symptoms with liquidly stools
- inadvertant passage of stool or gas
- dyspareunia
- perineal pain
Term
Aortoenteric fistulas present with:
Definition
rectal bleeding
Term
Lab studies performed with fistulas:
Definition
- Serum studies: Albumin, Prealbumin, BUN, Creatine, Electrolyes(APBCE)
- Abscess cultures
- UA or urine culture for colovescial fistulas
Term
Imaging study of choice for fistulas:
Definition
CT scan
Term
test to help delineate extend of communication of fistula with underlying bowel:
Definition
Fistulography
Term
Test to help ID fluid collections along fistula tract:
Definition
ultrasound
Term
Test that may be helpful in determine cause of fistula:
Definition
Barium enema and small bowel series
Term
Test that is helpful in determing the presence of possible enterovesicle fistula:
Definition
Cystography and CT cystography
Term
Fistulas involving the __ or __ need to be referred to a surgeon.
Definition
- bladder or vagina
Term
diet management with fistulas:
Definition
NPO, TPN initially
Term
Meds given in management of fistulas:
Definition
- somatostatin analogs _ inhibt release of serotonin and hormones involved in GI function
- immunosuppressive agents
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