wikidoc - User contributions [en]

Migraine

2014-02-25T20:11:13Z

Andrea Tamayo Soto:

__NOTOC__
'''For patient information, click [[{{PAGENAME}} (patient information)|here]]'''
{{Migraine}}

'''Editor-In-Chief:''' {{CMG}} {{AE}} {{ATS}}

==[[Migraine overview|Overview]]==

==[[Migraine historical perspective|Historical Perspective]]==

==[[Migraine classification|Classification]]==

==[[Migraine pathophysiology|Pathophysiology]]==

==[[Migraine triggers|Triggers]]==

==[[Migraine differential diagnosis|Differentiating Migraine from other Diseases]]==

==[[Migraine epidemiology and demographics|Epidemiology and Demographics]]==

==[[Migraine risk factors|Risk Factors]]==

==[[Migraine natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==
[[Migraine history and symptoms|History and Symptoms]] | [[Migraine physical examination|Physical Examination]] | [[Migraine laboratory findings|Laboratory Findings]] | [[Migraine CT|CT]] | [[Migraine MRI|MRI]]

==Treatment==

[[Migraine medical therapy|Medical Therapy]] | [[Migraine secondary prevention|Secondary Prevention]] | [[Migraine cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Migraine future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==

[[Migraine case study one|Case #1]]

{{WH}}{{WS}}
[[Category:Migraine]]
[[Category:Primary care]]
[[Category:Neurology]]
[[Category:Signs and symptoms]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Headaches]]
[[Category:Head and neck]]

Diverticulitis resident survival guide

2014-02-24T21:17:49Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease, causing fever, leukocytosis and lower abdominal pain. It could be simple or complicated, which includes gross or microscopical perforation, obstruction, the formation of abscesses or fistulization.

==Causes==

===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. [[Diverticulitis]] is a life-threatening condition and must be treated as such irrespective of the causes.

===Common Causes===
*[[Diverticulosis|Diverticular Disease]]
*Increased intracolonical pressure
*[[Constipation]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> '''Percutaneous Drainage''' ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= '''Surgery''' }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T20:53:36Z

Andrea Tamayo Soto: /* Definition */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease, causing fever, leukocytosis and lower abdominal pain. It could be simple or complicated, which includes gross or microscopical perforation, obstruction, the formation of abscesses or fistulization.

==Causes==

===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. [[Diverticulitis]] is a life-threatening condition and must be treated as such irrespective of the causes.

===Common Causes===
*[[Diverticulosis|Diverticular Disease]]
*Increased intracolonical pressure
*[[Constipation]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T20:36:26Z

Andrea Tamayo Soto: /* Definition */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease, causing fever, leukocytosis and lower abdominal pain. It could be simple or complicated, which includes perforation, obstruction, fistulization or the formation of abscesses.

==Causes==

===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. [[Diverticulitis]] is a life-threatening condition and must be treated as such irrespective of the causes.

===Common Causes===
*[[Diverticulosis|Diverticular Disease]]
*Increased intracolonical pressure
*[[Constipation]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T20:34:35Z

Andrea Tamayo Soto: /* Definition */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease. It could be simple or complicated, which includes perforation, obstruction, fistulization or the formation of abscesses.

==Causes==

===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. [[Diverticulitis]] is a life-threatening condition and must be treated as such irrespective of the causes.

===Common Causes===
*[[Diverticulosis|Diverticular Disease]]
*Increased intracolonical pressure
*[[Constipation]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T20:12:18Z

Andrea Tamayo Soto: /* Causes */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. [[Diverticulitis]] is a life-threatening condition and must be treated as such irrespective of the causes.

===Common Causes===
*[[Diverticulosis|Diverticular Disease]]
*Increased intracolonical pressure
*[[Constipation]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T19:28:14Z

Andrea Tamayo Soto: /* Do´s */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>
*Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.<ref name="pmid20224374">{{cite journal| author=Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA| title=Indications for elective sigmoid resection in diverticular disease. | journal=Ann Surg | year= 2010 | volume= 251 | issue= 4 | pages= 670-4 | pmid=20224374 | doi=10.1097/SLA.0b013e3181d3447d | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20224374 }} </ref>
*Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T19:22:06Z

Andrea Tamayo Soto: /* Don'ts */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==Don'ts==
*Do not perform [[colonoscopy]] and [[sigmoidoscopy]], when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a [[colostomy]] in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.<ref name="pmid9593792">{{cite journal| author=Ferzoco LB, Raptopoulos V, Silen W| title=Acute diverticulitis. | journal=N Engl J Med | year= 1998 | volume= 338 | issue= 21 | pages= 1521-6 | pmid=9593792 | doi=10.1056/NEJM199805213382107 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9593792 }} </ref>
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
*Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.<ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-24T18:59:58Z

Andrea Tamayo Soto: /* Do´s */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform [[colonoscopy]] and [[sigmoidoscopy]], approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a [[Nasogastric intubation|nasogastric tube]] if evidence of obstruction or [[ileus]].
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform [[Laparoscopic surgery]], as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.<ref name="pmid10987037">{{cite journal| author=Wexner SD, Moscovitz ID| title=Laparoscopic colectomy in diverticular and Crohn's disease. | journal=Surg Clin North Am | year= 2000 | volume= 80 | issue= 4 | pages= 1299-319 | pmid=10987037 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10987037 }} </ref>
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and [[abscess]]es formation.<ref name="pmid9117315">{{cite journal| author=Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J| title=Surgical management of complicated colonic diverticulitis. | journal=Br J Surg | year= 1997 | volume= 84 | issue= 3 | pages= 380-3 | pmid=9117315 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9117315 }} </ref>
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use [[ultrasound]] and [[MRI]] are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or [[abscess]]es >6.5cm in diameter.<ref name="pmid16322960">{{cite journal| author=Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ et al.| title=Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. | journal=Dis Colon Rectum | year= 2006 | volume= 49 | issue= 2 | pages= 183-9 | pmid=16322960 | doi=10.1007/s10350-005-0274-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16322960 }} </ref>
*Do recommend elective single stage [[colectomy]] for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of [[Stent#Urinary Tract|ureteral stents]] in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.<ref name="pmid17031654">{{cite journal| author=Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW| title=A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery. | journal=Int J Colorectal Dis | year= 2007 | volume= 22 | issue= 6 | pages= 683-7 | pmid=17031654 | doi=10.1007/s00384-006-0219-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17031654 }} </ref>
*Do consider the administration of non-absorbable oral antibiotics such as [[erythromycin]], [[neomycin]], [[flagyl]] and [[clindamycin]] before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.<ref name="pmid21429471">Fry DE (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21429471 Colon preparation and surgical site infection.] ''Am J Surg'' 202 (2):225-32. [http://dx.doi.org/10.1016/j.amjsurg.2010.08.038 DOI:10.1016/j.amjsurg.2010.08.038] PMID: [http://pubmed.gov/21429471 21429471]</ref> <ref name="pmid19485781">{{cite journal| author=Hayashi MS, Wilson SE| title=Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery? | journal=Surg Infect (Larchmt) | year= 2009 | volume= 10 | issue= 3 | pages= 285-8 | pmid=19485781 | doi=10.1089/sur.2008.9958 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19485781 }} </ref>

==Don'ts==
*Do not perform colonoscopy and sigmoidoscopy, when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a colostomy in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-21T21:16:11Z

Andrea Tamayo Soto:

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a nasogastric tube if evidence of obstruction or ileus.
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use ultrasound and MRI are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
*Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
*Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.

==Don'ts==
*Do not perform colonoscopy and sigmoidoscopy, when suspecting acute diverticulitis, because of the risk of perforation.
*Do not reverse a colostomy in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.
*Do not recommend elective resection solely on the patients age (<50 years old).
*Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-21T21:09:54Z

Andrea Tamayo Soto: /* Buckley Classification{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.200...

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

====Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>====

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a nasogastric tube if evidence of obstruction or ileus.
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use ultrasound and MRI are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
*Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
*Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

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Diverticulitis resident survival guide

2014-02-21T21:08:44Z

Andrea Tamayo Soto: /* European Association for Endoscopic Surgery clinical Classification{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Comm...

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

====European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>====

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

===Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>===

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a nasogastric tube if evidence of obstruction or ileus.
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use ultrasound and MRI are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
*Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
*Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-21T21:05:42Z

Andrea Tamayo Soto: /* Do´s */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

===European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>===

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

===Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>===

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a nasogastric tube if evidence of obstruction or ileus.
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Do use ultrasound and MRI are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
*Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
*Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-21T21:01:02Z

Andrea Tamayo Soto: /* Do´s */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[diverticulitis]] according to the American Society of Colon and Rectal Surgeons<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> and the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br> <div style="float: left; text-align: left;">
❑ [[Abdominal pain ]]<br>
:❑ Lower left quadrant <br>
❑ Abdominal or preirectal fullness <br>
❑ [[Fever]]<br>
❑ [[Leukocytosis]] <br>
❑ [[Nausea]] <br>
❑ [[Vomit]]s <br>
❑ [[Vesicointestinal fistula|Fecaluria]]<ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref> <br>
❑ [[Pneumaturia]]<br>
❑ [[Pyuria]]</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:'''<ref name="pmid21346548">{{cite journal| author=Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H| title=How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. | journal=Ann Surg | year= 2011 | volume= 253 | issue= 5 | pages= 940-6 | pmid=21346548 | doi=10.1097/SLA.0b013e3182113614 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21346548 }} </ref> <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous history of [[diverticular disease]] <br>
❑ Previous episodes of [[diverticulitis]] <br>
❑ Chronic [[Abdominal pain]] <br>
❑ Previous history of [[abdominal surgery]]<br>
❑ Dietary regime <br>
❑ History of:
:❑ [[Irritable bowel syndrome]] <br>
:❑ Inflammatory bowel disease <br>
:❑ [[Colitis]]<ref name="pmid17234553">{{cite journal| author=Lamps LW, Knapple WL| title=Diverticular disease-associated segmental colitis. | journal=Clin Gastroenterol Hepatol | year= 2007 | volume= 5 | issue= 1 | pages= 27-31 | pmid=17234553 | doi=10.1016/j.cgh.2006.10.024 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17234553 }} </ref> <br>
❑ [[Immunodeficiency]]<ref name="pmid1854245">{{cite journal| author=Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL| title=Acute diverticulitis. A complicated problem in the immunocompromised patient. | journal=Arch Surg | year= 1991 | volume= 126 | issue= 7 | pages= 855-8; discussion 858-9 | pmid=1854245 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1854245 }} </ref></div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Ectoscopy: <br>
:❑ Obesity <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the temperature <br>
❑ Abdomen: <br>
:❑ Rigidty <br>
:❑ Tendernes <br> </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <br><div style="float: left; text-align: left;">
❑ CT <br>
❑ Blood Count: <br>
:❑ Leukocytes <br>
❑ Abdominal X-rays with soluble contrast <br>
❑ [[Urianalysis]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[diverticulitis]] according to the American Journal of Gastroenterology<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref> and the American Society of Colon and Rectal Surgeons <ref name="pmid24509449">{{cite journal| author=Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD et al.| title=Practice parameters for the treatment of sigmoid diverticulitis. | journal=Dis Colon Rectum | year= 2014 | volume= 57 | issue= 3 | pages= 284-94 | pmid=24509449 | doi=10.1097/DCR.0000000000000075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24509449 }} </ref>

{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | A01= '''Initial Management''' }}
{{familytree | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | B01 | | | | | | | | | | | | B02 | | | | | | | | | | B01= '''Uncomplicated''' | B02= '''Complicated'''<ref name="pmid16885694">{{cite journal| author=Floch MH| title=A hypothesis: is diverticulitis a type of inflammatory bowel disease? | journal=J Clin Gastroenterol | year= 2006 | volume= 40 Suppl 3 | issue= | pages= S121-5 | pmid=16885694 | doi=10.1097/01.mcg.0000225502.29498.ba | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885694 }} </ref> }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | C01 | | C02 | | | | | | | | | | C03 | | | | | | | | | | C01='''Outpatient''' <div style="float: left; text-align: left; padding:1em;">
❑ Inmunocompetent patient <br> ❑Tolerated oral intake<br> ❑Single episode<br> ❑Mild to moderate pain </div>
| C02= '''Hospitalized''' <div style="float: left; text-align: left; padding:1em;"> ❑Unable to tolerate oral intake <br> ❑Severe pain <br> ❑Inmunocompromised patients </div>
| C03= <div style="float: left; text-align: left; padding:1em;"> ❑[[Abscess]] <br> ❑[[Phlegmon]] <br> ❑[[Obstruction]] <br> ❑[[Fistula|Fistulization]] <br> ❑[[Bleeding]] <br> ❑[[Sepsis]] </div> }}
{{familytree | | |!| | | |!| | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | D01 | | D02 | | | | | | | | | | D03 | | | | | | | | | | D01= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Oral regimens <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 500 - 700mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Trimethoprim]] (160mg / 12 hrs) - [[Sulfamethoxazole]] (800mg / 12hrs)<br>
❑[[Amoxicillin]]- clavulanate (875mg / 12hrs)
</div>
| D02= '''Medical Treatment'''<ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref> <div style="float: left; text-align: left; padding:1em;">
Intravenous regimen <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Quinolone]] (e.g. [[Ciprofloxacin]] 400mg / 12hrs) <br>
❑[[Metronidazole]] (500mg / 6 - 8 hrs) + [[Cephalosporin#Third generation|Third-generation cephalosporin]] (e.g. [[Ceftriaxone]] 1 - 2g / 12hrs)
❑[[Beta-lactam]] with [[Beta-lactamase]] inhibitor (e.g. [[Ampicillin sulbactam]] 3g / 6hrs)</div>
| D03= Stage the severity by using:<div style="float: left; text-align: left; padding:1em;">
❑ [[Diverticulitis resident survival guide#European Association for Endoscopic Surgery clinical Classification|European Association for Endoscopic Surgery clinical Classification]] <br>
❑ [[Diverticulitis resident survival guide#Buckley Classification|Buckley Classification]]
❑ [[Diverticulitis resident survival guide#Hinchey Classification|Hinchey Classification]]</div>}}
{{familytree | | | | | | |!| | | | | |,|-|-|-|-|-|+|-|-|-|-|.| | | | | | }}
{{familytree | | | | | | E01 | | | | E02 | | | | E03 | | | E04 | | | | | E01= If after 2 to 3 days patient:<div style="float: left; text-align: left; padding:1em;"> <br>
❑ Doesn't respond to treatment <br>
❑ Repeat episodes <br>
❑ Complicates </div>
| E02= Mild <br>
| E03= Moderate <br>
| E04= Severe }}
{{familytree | | | | | | |!| | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | F01 | | | | F02 | | | | F03 | | | F04 | | | | | F01= '''Surgical Consultation'''
| F02= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage I''' <br>
❑Small precolic abscess (<4cm in diameter) <br> ❑Without peritonitis </div>
| F03= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage II''' <br>
❑Peridiverticular abscess (>4cm in diameter)</div>
| F04= <div style="float: left; text-align: left; padding:1em;"> '''Hinchey Stage III and IV''' <br>
❑Generalized peritonitis <br>
❑Uncontrolled sepsis <br>
❑Uncontained visceral perforation <br>
❑Large inaccessible abscess </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | G01 | | | | G02 | | | |!| | | | | | G01= '''Treat conservatively''' <div style="float: left; text-align: left; padding:1em;"> <br> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑Pain control </div>
| G02= <div style="float: left; text-align: left; padding:1em;"> ❑ Bowel rest <br> ❑Broad - spectrum antibiotics intravenously <br> ❑CT-guided percutaneous drainage <br> ❑Pain control</div> }}
{{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | | | | | |!| | | | | | H01= If patient doesn't respond to treatment }}
{{familytree | | | | | | | | | | | | | | | |`|-|-|-|-|V|-|-|'| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | I01 | | | | | | | | I01= Surgery }}
{{familytree | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | }}
{{familytree | | | | | | | | | | | | | | | | J01 | | J02 | | J03 | | | | J01= Traditional two or three stage surgery | J02= One stage surgical approach if possible (generally after percutaneous drainage) | J03= Laparoscopy surgery if specialist available }}
{{familytree/end}}

===European Association for Endoscopic Surgery clinical Classification<ref name="pmid10094765">{{cite journal| author=Köhler L, Sauerland S, Neugebauer E| title=Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. | journal=Surg Endosc | year= 1999 | volume= 13 | issue= 4 | pages= 430-6 | pmid=10094765 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10094765 }} </ref>===

{| Class="wikitable"
|-
| '''Grades'''
| '''Clinical Description'''
|-
|Grade I <br>
*symptomatic <br>
*uncomplicated disease
|
*Fever <br>
*Abdominal pain
|-
|Grade II <br>
*recurrent <br>
*symptomatic disease <br>
| Recurrence of above
|-
| Grade III <br>
*complicated disease
|
* Abscess <br>
* Hemorrhage<br>
* Fistula<br>
* Phelgmom <br>
* Perforation <br>
* Obstruction
* Purulent and fecal peritonitis
|-
|}

===Buckley Classification<ref name="pmid18479497">{{cite journal| author=Sheth AA, Longo W, Floch MH| title=Diverticular disease and diverticulitis. | journal=Am J Gastroenterol | year= 2008 | volume= 103 | issue= 6 | pages= 1550-6 | pmid=18479497 | doi=10.1111/j.1572-0241.2008.01879.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18479497 }} </ref>===

{| Class="wikitable"
|-
|
| '''CT Findings'''
|-
|Mild <br>
|Bowel wall thickening
|-
|Moderate<br>
|
*Bowel wall thickening > 3mm
*Phelgmon or small abscess
|-
| Severe <br>
|
* Bowel wall thickening > 5mm<br>
* Perforation with subdiaphragmatic free air <br>
* Abscess > 5mm<br>
|-
|}

====Hinchey's Classification <ref name="pmid18003962">{{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18003962 }} </ref>====

{| Class="wikitable"
|-
| '''Stages'''
| '''CT Findings'''
|-
|Stage 1<br>
|
*Small confined precolic or mesenteric abscess
|-
|Stage 2<br>
|
*Large abscess confined to the pelvis
|-
| Stage 3<br>
|
* Perforated diverticulitis <br>
* Peridiverticular abscess has ruptured <br>
|-
|Stage 4
|
*Free rupture of diverticula into the peritoneal cavity
|-
|}

==Do´s==
*Colonoscopy and sigmoidoscopy could be performed approximately six weeks after the inflammatory process, in order to rule out other diseases.
*Do insert a nasogastric tube if evidence of obstruction or ileus.
*Do perform a percutaneous drainage if planning for a successful one stage procedure.
*Do perform surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
*Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
*Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
*Ultrasound and MRI are useful alternative in the initial evaluation.
*Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
*Elective single stage colectomy is viable for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
*Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
*Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-21T20:20:57Z

Andrea Tamayo Soto: /* Hinchey's Classification {{cite journal| author=Jacobs DO| title=Clinical practice. Diverticulitis. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2057-66 | pmid=18003962 | doi=10.1056/NEJMcp073228 | pmc= | url=http://www.ncb...

Diverticulitis resident survival guide

2014-02-21T20:09:09Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-21T19:34:42Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-21T17:47:41Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-21T17:37:00Z

Diverticulitis resident survival guide

2014-02-21T17:35:13Z

Diverticulitis resident survival guide

2014-02-21T17:32:50Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-21T17:05:05Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-20T19:07:05Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-20T17:29:44Z

Diverticulitis resident survival guide

2014-02-20T17:28:58Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-20T16:58:13Z

Andrea Tamayo Soto: /* Diagnostic Approach */

Diverticulitis resident survival guide

2014-02-20T16:56:22Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Diverticulitis resident survival guide

2014-02-20T16:07:31Z

Andrea Tamayo Soto: /* Diagnostic Approach */

Diverticulitis resident survival guide

2014-02-19T21:16:42Z

Andrea Tamayo Soto: /* Diagnostic Approach */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to diverticulitis

{{Family tree/start}}
{{familytree | A01 | A01= '''Characterize the symptoms:''' <br> <div style="float: left; text-align: left;">
❑ [[Chest pain]]<br>
:❑ Absence of physical exertion <br>
:❑ Duration> 20 minutes <br>
:❑ Radiation to the jaw or left arm
:❑ No relief with medications<br>
:❑ No relief with rest <br>
:❑ Worse with time <br>
❑ [[Nausea]] <br>
❑ Vomiting <br>
❑ Sweating</div>}}
{{familytree | |!| | }}
{{familytree | B01 | B01= '''Obtain a detailed history:''' <br><div style="float: left; text-align: left;">
❑ Age <br>
❑ Previous [[MI]] <br>
❑ Previous [[PCI]] or [[CABG]] <br>
❑ Cardiac risk factors: <br>
:❑ [[Hypertension]] <br>
:❑ [[Diabetes]] <br>
:❑ [[Hypercholesterolemia]] <br>
:❑ Tobacco use </div>}}
{{familytree | |!| | }}
{{familytree | C01 | C01= '''Examine the patient:''' <br> <div style="float: left; text-align: left;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Auscultate the heart searching for murmurs <br>
❑ Search for signs of [[CHF]]
:❑ Decreased air entry in the lungs
:❑ Edema in the extremities </div>}}
{{familytree | |!| | }}
{{familytree | D01 | D01= '''Order labs and tests:''' <br><div style="float: left; text-align: left;">
❑ [[EKG]] <br>
❑ Biomarkers <br>
:❑ Troponin I<br>
:❑ CK-MB <br>
❑ [[Creatinine]] <br>
❑ [[Glucose]] <br>
❑ [[Hemoglobin]] </div>}}
{{Family tree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to

==Do´s==

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-14T19:47:37Z

Andrea Tamayo Soto: /* Therapeutic Approach= */

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to

==Do´s==

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Diverticulitis resident survival guide

2014-02-14T19:38:59Z

Andrea Tamayo Soto: Created page with "__NOTOC__ {{CMG}}; {{AE}} {{ATS}} ==Definition== ==Causes== ===Life Threatening Causes=== ===Common Causes=== ==Management== ===Diagnostic Approach=== Shown below is an..."

__NOTOC__
{{CMG}}; {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===

===Common Causes===

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to

==Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to

==Do´s==

==Don'ts==

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Gastroenterology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T19:34:00Z

Andrea Tamayo Soto: /* Do´s and Don´ts */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>==
*Perform a metabolic evaluation in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of biliary stone disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform

==Don´ts<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>==
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:37:54Z

Andrea Tamayo Soto: /* Don´tsref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC180812...

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==Do´s and Don´ts==
====Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>====
*Perform a metabolic evaluation in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of biliary stone disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform

====Don´ts<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>====
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:36:52Z

Andrea Tamayo Soto: /* Do´s and Don´ts */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==Do´s and Don´ts==
====Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>====
*Perform a metabolic evaluation in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of biliary stone disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform

====Don´tsref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>====
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:33:25Z

Andrea Tamayo Soto: /* Do´s and Don´ts */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==Do´s and Don´ts==
====Do´s====<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>
*Perform a [[metabolic evaluation]] in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of [[biliary stone]] disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform

====Don´ts====<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

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{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:26:36Z

Andrea Tamayo Soto:

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==Do´s and Don´ts==
===Do´s====<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>
*Perform a [[metabolic evaluation]] in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of [[biliary stone]] disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform

===Don´ts====<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>
*Do not recommend calcium restrictions, as the may increase the urinary oxalate excretion.

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:05:45Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T17:04:20Z

Andrea Tamayo Soto: /* Definition */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention | F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T16:45:52Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention | F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T16:41:01Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram(-)]] bacili
*[[Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention | F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T16:38:20Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram(-)]] bacili
*[[Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention | F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

{| Class="wikitable"
|-
| ''''''
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-14T16:36:58Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram(-)]] bacili
*[[Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention | F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}

Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captorpil]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}

Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}

{| Class="wikitable"
|-
| ''''''
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-12T17:08:59Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram(-)]] bacili
*[[Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= | F02= | F03= }}
{{familytree | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | G01 | | G02 | | G03 | | | | | | | | | | | G01= | G02= | G03= }}
{{familytree/end}}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Nephrolithiasis resident survival guide

2014-02-12T16:25:12Z

Andrea Tamayo Soto: /* Therapeutic Approach */

__NOTOC__
{{CMG}} {{AE}} {{ATS}}

==Definition==

==Causes==

===Life Threatening Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment

===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]

==Management==

===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]] based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref>

{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]] <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | | D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}

===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>:

{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours)
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div> }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;">
</div>
| E02= <div style="float: left; text-align: left; padding:1em;">
</div>
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*Gram (-) bacili
*Gram (+) cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= | F02= | F03= }}
{{familytree | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | G01 | | G02 | | G03 | | | | | | | | | | | G01= | G02= | G03= }}
{{familytree/end}}

==References==
{{reflist|2}}

[[Category:Emergency medicine]]
[[Category:Medicine]]
[[Category:Resident survival guide]]
[[Category:Nephrology]]

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Nephrolithiasis resident survival guide

2014-02-12T14:20:34Z

Andrea Tamayo Soto:

Nephrolithiasis resident survival guide

2014-02-12T14:19:04Z

Andrea Tamayo Soto: /* Management */

Nephrolithiasis resident survival guide

2014-02-12T14:16:32Z

Andrea Tamayo Soto: /* Therapeutic Approach */

Nephrolithiasis resident survival guide

2014-02-12T14:14:56Z

Andrea Tamayo Soto: /* Diagnostic Approach */

Nephrolithiasis resident survival guide

2014-02-11T18:45:46Z

Andrea Tamayo Soto: /* Diagnostic Approach */

Nephrolithiasis resident survival guide

2014-02-11T18:39:19Z

Andrea Tamayo Soto: /* Diagnostic Approach */