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Gastroenterology and Hepatology Diverticular Disease Diagnosis Diverticular disorders of the colon include diverticular bleeding and diverticulitis. Diverticulitis is an inflammatory response following microperforation of a diverticulum and is characterized by LLQ abdominal pain; fever may be present. Diverticular bleeding occurs flollowing rupture of an arterythat has penetrated a diverticulum, is typically painless, and usually stops without therapy. DOil'T BE TRICKED o Pneumaturia, fecaluria, or recurrent/polymicrobial UTI suggests a diverticulitis-related colovesical flstula. Testing If clinical features highly suggest diverticulitis, imaging studies are unnecessary. If the diagnosis is unclear or if an abscess is suspected (severe pain, high fever, palpable mass), CT is indicated. Treatment For stable patients with diverticulitis, select a liquid diet and a 7- to 10-day course of oral antibiotics, such as ciprofloxacin and metronidazole. Hospitalize patients if they are unable to maintain oral intake for IV fluids and antibiotics. A small abscess may resolve with antimicrobial therapy alone. CT guided drainage can facilitate nonsurgical management of larger abscesses. Emergent surgery is required when conservative treatment fails or for peritonitis, sepsis, or perforation. A high-fiber diet is recommended to prevent recurrent diverticulitis. DOil'T BE TRICKED . Avoid colonoscopy in the setting of acute diverticulitis; air insufflation may increase the risk of perforation. . A colonoscopy should be performed following recovery to rule out colon cancer. Mesenteric Ischemia and lschemic Colitis Diagnosis The two most common GI ischemic disorders are acute mesenteric ischemia (AMI) and colonic ischemia. Causes include cardiogenic emboli, thrombosis, and low flow states owing to hypotension or vasoactive drugs. In AMI, leuko- cytosis, hemoconcentration, increased anion gap metabolic acidosis, and elevations in LDH and/or amylase levels are seen. 98

Gastroenterology and Hepatology STUDY TABLET Differential Diagnosis of Gl lschemic Syndromes Problem Symptoms Diagnosis Acute mesenteric ischemia Poorly localized severe abdominal pain, often CIA or selective mesenteric angiography out of proportion to physical findings; peritoneal signs signifu infarction Chronic mesenteric ischemia Postprandial abdominal pain, fear of eating, CTA, selective angiography, or MRA and weight loss; often, signs and symptoms of atherosclerosis in other vascular beds Colonic ischemia LLO abdominal pain and self-limited bloody Abdominal CT in all patients; colonoscopy diarrhea with biopsy, if possible DOil'T BE TRIGKED . Right-sided colonic ischemia may be the harbinger of AMI caused by involvement of the superior mesenteric artery and requires CTA or MRA. Treatment $TUOY TABLE; Treatment for Mesenteric lschemia and lschemic Colitis Condition Trcatment AMI Broad-spectrum a ntibiotics Surgical embolectomy or intra-arterial thrombolysis Resection of necrotic bowel Chronic mesenteric Surgical bypass or angioplasty with ischemia stenting Colonic ischemia Supportive care with lVfluids and bowel rest Colonlc lxhemia: CIscan showing segmental wall thickening and pericolonic fat stranding that is consistent with colonic ischemia. Differentiating Cholestatic and Hepatocellular Diseases Key Considerations Hepatocellular injury primarily results in elevated AST and ALT values. Virus- or drug-induced acute hepatitis usually causes serum aminotransferase elevations >1000 U/L (ALI > AST) and serum total bilirubin levels >15 mg/dl.

Colonlc lxhemia: CIscan showing segmental wall thickening and pericolonic fat stranding that is consistent with colonic ischemia. Differentiating Cholestatic and Hepatocellular Diseases Key Considerations Hepatocellular injury primarily results in elevated AST and ALT values. Virus- or drug-induced acute hepatitis usually causes serum aminotransferase elevations >1000 U/L (ALI > AST) and serum total bilirubin levels >15 mg/dl. . ALT values >5000 U/L usually result from acetaminophen hepatotoxicity or hepatic ischemia. . An AST/ALT ratio >2.0 suggests alcoholic hepatitis. . Prolonged PT/INR and low serum albumin values imply severe hepatocellular dysfunction. o Minimal ALT and AST elevations in a patient with obesity, hyperlipidemia, and hypertension suggest nonalcoholic liver disease. 99