Diverticulosis/diverticulitis, Acute Pancreatitis And Diarrhea

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Diverticulosis/Diverticulitis

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Diverticula is out-pouching from large intestine. With inflammation of one or more diverticula, diverticulitis is diagnosed. It's most commonly in sigmoid colon.

Usually LLQ pain, but sometimes with RLQ or suprapubic pain.

Pain severe and steady sometimes with urinary frequency.

Pain increases with ambulatory, coughing or moving.

PE: normal BS, LLQ tenderness with +/- palpable mass.

Hospitalize the toxic and febrile for IV antibiotics.

Image: CT of abdomen.

Contraindicated to do colonoscopy or sigmoidoscopy during acute attack for risk of perforation.

Recommend high fiber, low fat diet. Increase fiber intake gradually to avoid distention and flatulence.

Fiber: Metamucil.

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Acute pancreatitis.

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Associated with chronic alcoholism and gallstones.

Also occurs due to idiopathic or secondary to perforated PUD, trauma, neoplasm, hypercalcemia, hyperlipidemia, drug use, and viral infection.

Pancreas is the only endocrine and exocrine gland. Insulin and glucagon are released secondary to endocrine function. It also manufactured, stored and excretes enzymes that are send to proximal small intestine to aid in digestion of fat, protein, and carbs.

These enzymes are: amylase, lipase and trypsin.

Trypsin digest protein.
Amylase and lipase digest carbs and fats.

Pancreas is composed primarily of protein. Pancreatitis occurs when trypsin is activated.

It usually affect 40-60 year old.
Older Pts tend to have gallstone pancreatitis as compared to younger ones who have alcoholism pancreatitis.

Presentation: abrupt onset deep, gnawing, constant epigastric pain, radiate to back; last > 24 hrs. With N/V, fever, diaphoresis, toxic look, dehydration, positive orthostatic, diminished or absent BS.

Pain increase with food or alcohol intake.

Relief with leaning forward.

PE: low grade fever, note for Turner's sign (flank ecchymosis) or Cullin's sign (Periumbilical ecchymosis)= poor prognosis.

Labs: check amylase= increase 1.5 x normal. Return to normal in 1-3 days. It is seen in other sources such as salivary glands. Also increase in renal failure and macroamylasemia.

Urine sample of affected pt will lack amylase because too large to fit through kidneys.

Lipase increases and stay elevated for 7-10 days.

LFTs: increase suggest gallstone pancreatitis.

ALT is 3x, there is predictive value for gallstone pancreatitis in nonalcoholic.

Check hypocalcemia, hypoalbuminuria, hyperglycemia, leukocytosis (15-20); pulse ox, glucose and CXR.

Check BUN/Cr with dehydration.

Treatment: supportive (hydration, rest, pain management, adequate nutrition).

Chronic pancreatitis is associated with exocrine deficiency. DM management is needed, and malabsorption, chronic pain syndrome.

Pt needs to d/c alcohol.
GI referral for ERCP.

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Diarrhea

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Viral gastroenteritis= common in all age group.

Acute= onset less than 3 weeks.

Viral causes = rotaviruses (kids) and enteric adenoviruses and Norwalk-like agent (adult).

Presentation: abdominal pain preceded by N/V, abrupt onset, tenesmus. Fever most in children.

Diarrhea tends to be watery, but contains no blood, mucus or pus.

Stool C&S to identify organism.

Rotavirus: diarrhea before vomiting. Last 4 days ( usually 5-6).

Norwalk: last 1-3 days. With variable WBC and sometimes fever.

Adenovirus: last 5-12 days.

If symptoms persist more than 14 days, re-evaluate.

Treatment: supportive. Avoid fat in diet. Clear fluid first day. Utilize BRAT diet.

Bloody diarrhea caused by: shigella, salmonella, E.Coli, campylobactory, yersinia, C.diff (fecal leukocyte present); or other inflammatory condition such as Crohn's disease or IBS.

Treatment is often with antibiotic.

E.coli O157:H7= cause bloody diarrhea following ingestion of undercooked ground beef; or can be spread via contaminated water or person to person. Can also be non-bloody.

Incubation period 4-5 days. Symptoms: abdominal cramps, non bloody diarrhea, which becomes bloody in 2-3 days. May have N/V and low grade fever.

Do not give antimotility or antibiotics routinely of increase induction of hemolytic uremic syndrome or TTP.

This E.Coli is sorbitol negative.

Fecal leukocytes are absent in viral infections such as giardia, cryptosporidium, vibrio, cholera, sprue or lactose intolerance.