Diverticulitis

FOAM
http://academiclifeinem.com/paucis-verbis-outpatient-treatment-for-diverticulitis/
http://radiopaedia.org/articles/hinchey-classification-of-acute-diverticulitishttp://www.emlitofnote.com/2013/01/diverticulitis-sinusitis-of-colon.htmlhttp://www.alifeatrisk.com/2013/03/diagnosis-of-diverticulitis-with-hands.htmlhttp://www.bmj.com/content/346/bmj.f928
http://www.criticalultrasoundjournal.com/content/5/S1/S5
http://radiopaedia.org/cases/acute-meckels-diverticulitis
http://radiopaedia.org/articles/diverticulitishttp://www.sciencedirect.com/science/article/pii/S0735675700900044
http://www.bmj.com/content/332/7536/271
http://learning.bmj.com/learning/module-intro/colonic-diverticular-disease.html?moduleId=5003332&searchTerm=%E2%80%9Cdiverticulitis%E2%80%9D&page=1&locale=en_GB

Introduction
Diverticulosis—the presence of diverticula that are asymptomatic
Diverticular disease—diverticula associated with symptoms
Diverticulitis—evidence of diverticular inflammation (fever, tachycardia) with or without localised symptoms and signs (LIF pain). Normally caused by gram negative bacteria.
Complicated diverticulitis—perforation*, abscess, fistula, stricture/obstruction

Diverticulitis affects over half of the population over 65years, with a prevalence that increases with age. You can get diverticulitis in young people.
85% of colonic diverticulitis will recover with treatment but some patients may have complications such as abscesses, fistulas, obstruction and perforation.
Recurrent diverticulitis is observed in 7-42% of people with diverticular disease and there is a 3% yearly risk of a further attack following resolution of the initial episode. 

The pathogenesis incompletely understood. Inverse relationship between incidence and fibre content of the diet.
Once diverticula have formed, stool may become thickens within the neck. In a process similar to appendicitis, the obstructing faecalith promotes secretion of mucus and bacterial overgrowth, which distends and erodes the thin walled diverticulum. Localised ischaemia develops, enabling translocation of mucosal bacteria and eventual perforation.



Diverticulosis is the most common structural abnormality of the colon and in the Western world. It affects 5% of people in their fifth decade and up to 50% of those older than 80.

Diverticula arise mainly in the distal colon, with 90% of patients having sigmoid colon involvement compared with only 15% on the right side. In contrast, Asian populations show predominantly right sided involvement, this may have a genetic involvement


Symptoms
Colicky abdominal pain, normally left sided.
You can get a meckel's diverticulitis which causes right sided pain.
Patients get bloating, or flatulence, which is exacerbated by eating and relieved by passage of flatus or stool.

There is usually little to find on clinical examination of patients with diverticulosis.

• Diverticular disease  mild left iliac fossa tenderness. 
• Acute diverticulitis typically left iliac fossa tenderness + general signs of infection
• Remember coeliac disease can cause diarrhoea and may be associated with other conditions such as dermatitis herpetiformis - this is an itchy vesicular rash on the extensor surfaces of the arms and legs

Diagnosis
Hinchey classification of acute diverticulitis:
    stage 1a - phlegmon
    stage 1b - diverticulitis with pericolic or mesenteric abscess
    stage 2 - diverticulitis with walled off pelvic abscess
    stage 3 - diverticulitis with generalised purulent peritonitis
    stage 4 - diverticulitis with generalised faecal peritonitis

CT as good as USS but has slightly higher diagnostic accuracy. CT should be done in critically unwell patient without delay to rule out complicatied diverticulitis.  


TreatmentUncomplicated diverticulitis might be treated as outpatient if:
 - can tolerate POs
 - no significant co-morbidities
 - able to obtain antibiotics
 - have adequate pain control
 - access to follow up and social support
The role of antibiotics is controversial. One small study suggests diverticulitis might be a self-limiting process rather than one that requires antibiotics?

Chronic Treatment
 - High fibre diet
- Exercise
- Laxatives (controversial evidence)
- Antispasmodics

IBS

I often wonder if patients have IBS, so was quite pleased to find the official IBS diagnosis criteria, and the NICE guidelines.

Diagnosis
Using a combination of NICE guidelines and Rome III guidelines, consider assessment for IBS if you have any of the following symptoms:
- Abdominal pain or discomfort (at least 3 days/month in the last 3 months)
- Bloating
- Change in bowel habit - change in frequency or form of stool

Treatment
Increase soluble fibre (eg oats)
Reduce insoluble fibre (eg wholemeal and high-bran cereals)

Laxatives
Lactulose is not recommended.
Osmotic laxatives such as magnesium hydroxide (milk of magnesia) or macrogol (polyethylene glycol; Movicol®) may be recommended.
Stimulants not recommended
Bulk-forming laxatives (ispaghula husk, methylcellulose, sterculia)

Painkillers
Mebeverine hydrochloride (Colofac®) or alverine citrate (Spasmonal®)
Peppermint oil

Antimuscarinics (anticholinergics) such as hyoscine butylbromide (Buscopan®) are poorly selective and are likely to cause antimuscarinic adverse effects.

Abdominal Pain

These summaries are for me - and they're online so that I know exactly where to find them where ever I am!

Kidney - Renal Colic and Urinary Retention

Renal Colic 

Diagnosis
85-90% present with haematuria

Uric acid stone formers have acidic urine, as to cystinurics
Calcium stones have alkaline urine

Imaging
Look carefully for stones at the points where they may get stuck:

    The pelviureteric junction where the large diameter of the renal pelvis decreases to that of the ureter (2-3 mm)
    The pelvic brim: as the ureters arch over the iliac vessels, they narrow to about 4 mm
    The vesicoureteric junction where the ureter narrows to 1-5 mm - this is the most common area
 
 Treatment
- Buscopan may be useful but no hard evidence. 

Physiology
- The most common types of stone are:

calcium-containing stones - 70%
    infection stones (struvite/ triple phosphate) - 15-20%
    uric acid stones - 5-10%    cystine stones - 1-3%
    xanthine stones - 1%

BMJ article
Acute Urinary Retention
 PSA: The serum PSA can be artificially elevated in acute urinary retention and after instrumentation of the urinary tract (catheterisation). It can also be artificially raised by infection (cystitis, prostatitis), prostatic biopsy itself, and after sexual intercourse but not by a gentle rectal examination. PSA should only be measured in the acute setting if there is a suspicious rectal examination or a concomitant history suggesting metastatic disease (bone pain, leg weakness).

Tamsulosin: less postural hypotension, more retrograde ejaculation (better in elderly men).

Alfusozin: more postural hypotension, less retrograde ejaculation (better in younger men).

Abdominal Pain

The CEM syllabus is quite vague. There are probably far too many resources out there about abdominal pain. I think the hardest thing is persuading the surgeons to take abdominal pain, especially if bloods aren't abnormal!

elFH (and EnlightenMe)
There are many e-learning modules:
Anorectal disease
Gall Bladder Disease
Appendicitis
Pancreatitis
Urinary Retention
Haematuria

Enlighten Me
Abdominal Pain without Shock module - this was quite basic but a useful reminder of the embryology, and good consolidation.
CEMPaedia on Abdominal Pain
CEMPaedia on Appendicitis

Doctors.net
Kidney Stones 
Acute Abdomen
AXR Interpretation - This module was brilliant and covered more than just the basics. A summary card with the stats and pictures (like the PV cards on academic life in EM) would be great.
AXR Quiz - a very useful quiz, with excellent emphasis on what features to look out for. 

Other
Calgary Guide - this website is brilliant for looking at the pathophysiology of disease.
Medical causes of abdominal pain
Emergency Medicine Ireland - If I'd watched this podcast before seeing a patient with abdo pain, I think they'd have been diagnosed. If only I could remember their name!