Rosen & Barkin's 5-Minute Emergency Medicine Consult (221 page)

• ICU if unstable with massive hemorrhagic diverticulosis
  
• Mild or intermittent hemorrhagic diverticulosis that is otherwise stable so as to determine site of bleeding and evaluate need for definitive treatment
  

• Uncomplicated, symptomatic diverticulosis
  
• Stable with trace heme-positive stool, negative gastric aspirate, no anemia, and no other complaints
  

GI follow-up for colonoscopy

• Colonoscopy within 48 hr of initial presentation for stable patients
  
• Discontinue aspirin and NSAIDs
  
• Increase intake of dietary fiber
  
• No evidence for avoidance of nuts, corn, popcorn
  

• 15% with hematochezia have an upper GI source
  
• Most cases (75–95%) resolve spontaneously or with conservative management
  
• Massive blood loss seen in 9–19% of patients, especially those with comorbid diseases or advanced age
  
• Colonoscopy is the initial diagnostic procedure of choice in stable patients
  

• Bono MJ. Lower gastrointestinal tract bleeding.
  Emerg Med Clin North Am
  . 1996;14(3):547–556.
  
• Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: Results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery.
  Surg Endosc
  . 1999;13(4):430–436.
  
• McGuire HH Jr. Bleeding colonic diverticula: A reappraisal of natural history and management.
  Ann Surg
  . 1994;220(5):653–656.
  
• Strate LL, Liu YL, Aldoori WH, et al. Obesity increases the risks of diverticulitis and diverticular bleeding.
  Gastroenterology
  . 2009;136:115–122.
  
• Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis.
  Gastroenterol Clin North Am
  . 2009;38(3):513–525.
  
• Wilkins T, Baird C, Pearson AN, et al. Diverticular bleeding.
  Am Fam Physician
  . 2009;80(9):977–983.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Diverticulitis
  
• GI Bleeding
  

CODES

• 562.10 Diverticulosis of colon (without mention of hemorrhage)
  
• 562.12 Diverticulosis of colon with hemorrhage
  
• 751.5 Other anomalies of intestine
  

BASICS

• Patients’ descriptions of symptom quality (vertigo, lightheadedness, disequilibrium, or “other”) are frequently misleading and should not be the basis of clinical decision making.
  
• An approach based on associated symptoms, timing and triggers of the dizziness followed by a targeted physical exam looking for telltale signs is less prone to subjective errors of language and possibly more likely to yield a specific diagnosis.
  
• There are 4 “timing and triggers” categories:
  
  • Acute vestibular syndrome (AVS)
    
  • Abrupt onset of persistent dizziness
    
  • Episodic vestibular syndrome (EVS)
    
  • Spontaneous episodes of dizziness lasting many minutes to hours
    
  • Positional vestibular syndrome (PVS)
    
  • Very brief episodes (usually lasting 20–50 sec) that are triggered by head or body position movement
    
  • Chronic vestibular syndrome (CVS)
    
  • Gradual onset of dizziness lasting weeks to months or longer
    

• General medical (49%):
  
  • Arrhythmia
    
  • Hypoglycemia and other toxic metabolic causes
    
  • Hypovolemia of any cause
    
  • Sepsis and infections
    
  • Low cardiac output states of any cause
    
• Otologic/vestibular (33%):
  
  • Benign paroxysmal positional vertigo (BPPV)
    
  • Labyrinthitis and vestibular neuritis
    
• Neurologic (11%):
  
  • Stroke and transient ischemic attack (TIA)
    
  • Vestibular migraine
    
• Psychiatric (7%):
  
  • Anxiety and depression
    

DIAGNOSIS

Define the timing and triggers category and determine if the ROS suggests a particular serious diagnosis:

• Is the dizziness abrupt or gradual in onset?
  
• Is the dizziness intermittent or persistent?
  
• If intermittent, how long do episodes last?
  
• If intermittent, are the episodes triggered by head or body position movement?
  
• Are there any hearing or neurologic symptoms?
  
• Has the patient had recent head injury or started any new medications?
  
• Does the ROS suggest an acute medical issue; not an encyclopedic list, but examples include:
  
  • Headache – stroke, dissection, or tumor
    
  • Ear pain – mastoiditis, otitis media
    
  • Hearing changes – Ménière disease or labyrinthitis
    
  • Neck pain – vertebral dissection
    
  • Fever – systemic infection
    
  • Dyspnea – pulmonary embolism, pneumonia, or anemia
    
  • Chest pain – ACS or pulmonary embolism
    
  • Fluid losses – orthostatic hypotension, hypovolemia
    
  • Pregnancy – ectopic pregnancy, pre-eclampsia
    

• Vital signs
  
• Stand patient to test for clinical signs of orthostatic hypotension
  
• Otoscopic evaluation
  
• Cardiac exam – is there a murmur or S3?
  
• Neurologic exam
  
  • CN II-XII. In particular, is there nystagmus, and if so, what type (see below)?
    
  • Observe gait
    
  • Cerebellar exam (finger to nose/heel to shin)
    
  • Dix-Hallpike maneuver only for intermittent symptoms
    
• HINTS exam (only for patients with AVS)
  
  • This is a 3-part more detailed oculomotor exam (head impulse test, nystagmus testing, and test for skew deviation)
    
  • For acute (<48 hr) of symptoms this exam has been shown to be more sensitive than MRI. If exam is concerning obtain MRI orneurology consultation.
    
• Head impulse testing (vestibulo-ocular reflex)
  
  • Patient fixes gaze on examiner’s nose
    
  • Move patient’s heads rapidly about 20° in the horizontal plane
    
• If reflex is intact their eyes will stay fixed on your nose (vestibulo-ocular reflex is intact) and a central cause such as cerebellar stoke may be at play. If there is a corrective saccade (eye moves with head and then snaps back toward your nose), this suggests a peripheral cause (vestibular neuritis or labyrinthitis)
  
• Nystagmus
  
  • Have patient track your finger to all visual fields.
    
    • Does the direction of horizontal nystagmus change with change in direction of gaze? (i.e., when patient looks left, is fast component beating to left; when patient looks right, is fast component toward the right)?
      
    • Direction-changing, vertical or torsional nystagmus (in a patient with the AVS) strongly suggests a central cause.
      
    • Direction-fixed nystagmus (always in same direction independent of direction of gaze) suggests peripheral cause.
      
• Tests of skew
  
  • Alternating cover test
    
    • Have the patient look at your nose and cover one of their eyes with your hand
      
    • Rapidly uncover the 1st eye; cover the other one and observe if there is a rapid vertical eye movement (the amplitude can be quite small).
      
    • Continue to alternately cover and uncover each eye (focusing on 1 eye) in rapid succession.
      
  • A rapid vertical corrective saccade (up or down) strongly suggests a central process.
    

The only mandatory workup is history and physical exam. Using these, one can often make a specific diagnosis.

• Triage: Identify abnormal vital signs, changes in mentation or gross focal deficits in primary survey
  
  • Focused history to elicit other complaints such as chest pain, headache, and change in hearing that will guide evaluation
    
• Timing: Distinguish between intermittent and chronic symptoms considering relevant conditions for each
  
• Triggers: For intermittent symptoms consider the immediate context of episodes
  
• Telltale signs: HINTS exam for acute dizziness