The patient with symptoms of diverticulosis may progress into acute diverticulitis. He or she may have experienced several episodes of diverticulosis before this change or, equally, this may be the first episode. This disease is an acute inflammation and infection of the diverticulum, giving rise to symptoms of acute pain, fever and nausea, and necessitates hospital admission. Diverticulitis can also mean perforation, fistula or abscess. Careful assessment of the patient is essential at this stage. Occasionally the diagnosis is clear as a result of the clinical picture and findings; other times more investigations are required. A plain abdominal radiograph provises a baseline for subsequent comparisans. A barium enema is not indicated if there is a clinical picture of perforation and for the same criteria that apply to endoscopy. Abdominal ultrasonography may rule out female gynaecological and pelvic problems that can have similar symptoms (Ripolles et al., 2003). Computed tomography (CT) with contrast has been seen to be of value in diagnosing diverticular disease (Rotert et al., 2003).
Perforation and peritonitis may be the first indication that a patient is suffering from diverticulitis. The patient may have had severe abdominal pain for up to 1 week before calling the general practitioner (GP) and, when elderly, the patient may be found to be quite ill and debilitated at home. The GP will refer the patient straight to hospital with a tentative diagnosis of perforation of the bowel or obstruction and abdominal pain, with a query as to cause.
The patient will present in the accident and emergency department (A&E) in acute distress and pain; equally he or she may present with vague abdominal pain and may already have perforated. Another reason for admission to the A&E is haemorrhage. Blood loss from a bleeding diverticulum is often significant, dramatic and without warning (Keighley and Williams, 1997). When the rectal bleeding does not require immediate hospital admission, patients are sent to the rapid access rectal bleeding clinic to have the bleeding investigated in order to rule out other pathology, i.e. colorectal cancer. The most likely cause of the bleeding is an erosion of the blood vessel where the diverticulum protrudes through the wall of the colon. A diagnosis of the origin of bleeding is imperative to rule out other pathology.
The patient in A&E will frequently require resuscitation with intravenous fluids, intravenous antibiotics and analgesia. The symptoms of an acute attack of diverticulitis can be similar: of gradual onset or a sudden acute attack of severe abdominal pain. The patient may or may not have noticed any other warning signs of being ill before being aware of acute abdominal pain. These are the symptoms that will bring the patient to A&E, usually in the middle of the night. Krukowski (1998) suggested that the policy in the care of a patient with acute diverticulitis is to manage the patient medically for up to 3 days before taking a decision to operate, provided that the patient's condition does not deteriorate. With this policy there has been a marked reduction in emergency surgery during the past 20 years with very little disadvantage to the patient (Krukowski, 1998).
The patients will be treated medically with intravenous antibiotics, pain relief, a nasal gastric tube for gastric suction and intravenous fluids. Some patients, however, will require surgical treatment for a perforated bowel. The symptoms of a perforated bowel are:
• Low-grade fever or a high temperature
• Raised white blood cell count (WBC)
• Nausea and vomiting
• Change in bowel habit
• Urinary symptoms associated with irritation of the bladder from the inflamed sigmoid colon near to the bladder
Diagnosis of the diverticulitis will require investigations to differentiate from other problems, including appendicitis and colonic carcinoma. Physical examination by the doctor will show an absence of or dull bowel sounds in acute diverticulitis, localized left iliac fossa tenderness, and a palpable mass may be felt. On digital rectal examination a mass may be felt or tenderness noted.
In the acute phase of diverticulitis it is important to have an accurate diagnosis. A straight abdominal radiograph is the first investigation to be ordered. Blood tests are important, because they will show a low haemoglobin or raised WBC.
This is then followed by CT if the results from the straight abdominal radiograph show this to be necessary. A variety of other abdominal radiological investigations is also available. The gastrograffin enema is occasionally used in patients who are diagnosed as being in abdominal obstruction. This water-soluble medium does not cause harm to the patient if it leaks out through a perforation, because it will be absorbed in time. The gastrograffin also may help free the bowel from its obstruction by increasing the water flow through the narrowing.
The pneumocolon CT is currently being used at the authors' hospital. The rationale for this examination for the elderly patient is that it is kinder than the barium enema and the actual images show more of the internal structure of the abdomen as well as the bowel. The patient is still required to have the bowel preparation before the examination.
The procedure of pneumocolon introduces air into the bowel instead of barium, and there is no need for the manipulation of the patient to view the bowel or coat the lining with medium. The patient is placed in the CT scanner; it is a safe and accurate method of diagnosis for perforation or diverticular mass. The disadvantage is that biopsies and polyp removal are not possible but, unlike with the barium enema, patients could have a colonoscopy performed the same day, thereby alleviating the need for further bowel preparation.
Endoscopy in the acute phase of diverticulitis is not recommended because of the high risk of perforation. The endoscopy can be performed at a later date in the non-acute patient who, although there is still at risk of perforation, is at a lesser risk.
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