1000-2000 5 ьшò

–The routine use of antibiotics in uncomplicated diverticulitis is controversial (3,5)[C].

–Outpatient oral antibiotics: Cover for anaerobes and gram-negatives with: Afluoroquinolone (ciprofloxacin 750 mg BID or levofloxacin 750 QD) plus metronidazole 500 mg TID (may use clindamycin if metronidazole intolerant) or

Trimethoprim/sulfamethoxazole DS BID plus metronidazole 500 mg TID

Treat for 7 to 10 days.

–Inpatient: Use IV antibiotics.

Monotherapy with a β-lactam/β-lactamase inhibitor: piperacillin/tazobactam (3,375 g IV QID) or ampicillin/sulbactam 3 g IV q6h or ertapenem (1 g IV QD)

Penicillin-allergic patient: quinolone (levofloxacin 750 mg IV QD plus metronidazole 500 mg IV TID)

Unresponsive or severe disease: imipenem or meropenem

–Recurrences of acute diverticulitis may be decreased by using mesalamine

± rifaximin or probiotics.

Diverticular bleeding

–Consider vasopressin 0.2 to 0.3 units/min through selective intra-arterial catheter.

Precautions

–Avoid morphine and other opiates that may increase intraluminal pressure or promote ileus.

–Increased fiber intake is not recommended in the acute management of diverticulitis.

Second Line

Outpatient: amoxicillin/clavulanate monotherapy (875/125 mg BID) (contraindicated in patients with clearance <30 mL/min) or moxifloxacin (400 mg PO QD) plus metronidazole (500 mg PO TID)

Severely ill inpatients: ampicillin (500 mg IV q6h) + metronidazole (500 mg IV TID) + a quinolone or ampicillin + metronidazole + an aminoglycoside

ISSUES FOR REFERRAL

Acute diverticulitis patients should follow up with a gastroenterologist or surgeon after resolution of diverticulitis (6 to 8 weeks) for colonoscopy to exclude malignancy, fistula, strictures, or inflammatory bowel disease (3).

Acute complicated diverticulitis should have appropriate surgical and critical care/infectious disease consultations.

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SURGERY/OTHER PROCEDURES

Acute diverticulitis

–Indications for emergent surgery: peritonitis, uncontrolled sepsis, perforation, obstruction

–Consultation to interventional radiology to drain large abscesses (>4 cm) for Hinchey I and II diverticulitis (3)

–Generally Hinchey III or IV diverticulitis requires surgery in the same hospital admission.

–Elective resection in recurrent diverticulitis is a case-by-case decision. It is typically advised after recovery from a bout of complicated diverticulitis which is treated nonoperatively (3).

–Immunocompromised patients are more likely to present with acute complicated diverticulitis, fail medical management, and have

complications from elective surgery. Diverticular bleeding

–Endoscopy and hemostasis by epinephrine injection, electrocautery, or clipping (4)

–Angiography can identify bleeding source and embolize the feeding artery (4).

–Massive or recurrent bleeding requires limited or subtotal colectomy to control hemorrhage.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Probiotics such as Lactobacillus casei and Escherichia coli Nissle 1917 have been used to prevent recurrence with mixed success.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Admit for systematic toxicity, sepsis, and/or peritonitis.

Admit patients who cannot tolerate oral intake or who need IV fluids, analgesics, antibiotics, and bowel rest.

ONGOING CARE

DIET

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Bowel rest with NPO during acute diverticulitis; advance diet as tolerated as bowel function returns

Patients with known diverticulosis or a history of diverticulitis should consume a high-fiber diet to prevent recurrence (5).

Avoiding nuts and popcorn is not necessary (5).

PROGNOSIS

Good with early detection and prompt treatment

After first episode of diverticulitis, there is a 33% chance of recurrence. After a second episode, there is a 66% chance of further recurrence.

Most complications occur during first bout of diverticulitis.

Younger patients are more likely to have recurrence.

Rebleeding occurs in up to 6%.

COMPLICATIONS

Hemorrhage, perforation, peritonitis, obstruction, abscess, or colovesicular/colovaginal fistula

REFERENCES

1.Strate LL, Modi R, Cohen E, et al. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol. 2012;107(10):1486–1493.

2.Sheth AA, Longo W, Floch MH. Diverticular disease and diverticulitis. Am J Gastroenterol. 2008;103(6):1550–1556.

3.Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284–294.

4.Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 1998;93(8):1202–1208.

5.Stollman N, Smalley W, Hirano I; for AGAInstitute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149(7):1944– 1949.

ADDITIONALREADING

Boynton W, Floch M. New strategies for the management of diverticular disease: insights for the clinician. Therap Adv Gastroenterol. 2013;6(3):205–

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213.

Katz LH, Guy DD, Lahat A, et al. Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis. J Gastroenterol Hepatol. 2013;28(8):1274–1281. Templeton AW, Strate LL. Updates in diverticular disease. Curr Gastroenterol Rep. 2013;15(8):339.

CODES

ICD10

K57.90 Dvrtclos of intest, part unsp, w/o perf or abscess w/o bleed

K57.30 Dvrtclos of lg int w/o perforation or abscess w/o bleeding K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding

CLINICALPEARLS

Diverticulosis is common in elderly patients with a sedentary lifestyle who consume a Western diet.

Diverticulosis patients benefit from a high-fiber diet.

Acute uncomplicated diverticulitis can be treated with outpatient therapy with oral antibiotics.

Acute complicated diverticulitis requires hospitalization, bowel rest, and IV antibiotics.

The decision for surgery in diverticulitis and diverticular bleeding is made on a case-by-case basis.

Surgical consultation is recommended in acute complicated diverticulitis.

After an episode of diverticulitis, patients should follow up to undergo colonoscopy to rule out malignancy.

Diverticular disease is a common cause of GI bleeding.

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DOMESTIC VIOLENCE

Rhonda A. Faulkner, PhD Luis T. Garcia, MD

BASICS

DESCRIPTION

Domestic violence (DV) is the behavior in any relationship that is used to gain or maintain power and control over an intimate partner.

May include physical, sexual, and/or emotional abuse; economic or psychological actions; or threats of actions that influence another person

Although women are at greater risk of experiencing DV, it occurs among patients of any race, age, sexual orientation, religion, gender, socioeconomic background, and education level.

Synonym(s): intimate partner violence (IPV); spousal abuse; family violence

EPIDEMIOLOGY

Incidence

In the United States, lifetime estimates of DV are 22–39% of women, with 10– 69% reporting physical assault by an intimate partner at some point in their lifetime. DV affects both sexes, but women are more likely to be victims than men and are more likely to report partner violence.

Prevalence

DV occurs in 1 of 4 American families. Nearly 5.3 million incidents of DV occur each year among U.S. women aged ≥18 years and 3.2 million incidents among men.

DV results in nearly 2 million injuries and up to 4,000 deaths annually in the United States.

14–35% of adult female patients in emergency departments report experiencing DV within the past year.

Costs of DV are estimated to exceed $5.8 billion annually, of which $4.1 billion are for direct medical and mental health services.

DV survivors have a 1.6- to 2.3-fold increase in health care use compared with the nonabused population.

Geriatric Considerations

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4–6% of elderly are abused, with ~2 million elderly persons experiencing abuse and/or neglect each year. In 90% of cases, the perpetrator is a family member.

Elder abuse is any form of mistreatment that results in harm or loss to an older person; may include physical, sexual, emotional, financial abuse, and/or neglect

Pediatric Considerations

>3 million children aged 3 to 17 years are at risk of witnessing acts of DV.

~1 million abused children are identified in the United States each year.

Children living in violent homes are at increased risk of physical, sexual, and/or emotional abuse; anxiety and depression; decreased self-esteem; emotional, behavioral, social, and/or physical disturbances; and lifelong poor health.

Pregnancy Considerations

DV occurs during 7–20% of pregnancies. Women with unintended pregnancy are at 3 times greater risk of DV. 25% of abused women report exacerbation of abuse during pregnancy. There is a positive correlation between DV and postpartum depression.

RISK FACTORS

Patient/victim risk factors

–Substance abuse

–Poverty/financial stressors/unemployment

–Recent loss of social support

–Family disruption and life cycle changes

–History of abusive relationships or witness to abuse as child

–Mental or physical disability in family

–Social isolation

–Pregnancy

–Attempting to leave the relationship

Perpetrator risk factors

–Substance abuse (e.g., PCP, cocaine, amphetamines, alcohol)

–Young age

–Unemployment

–Low academic achievement

–Witnessing or experiencing violence as child

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–Depression

–Personality disorders

–Threatening to self or others

–Violence to children or violence outside the home

–Owns weapons

Relational risk factors

–Marital conflict

–Marital instability

–Economic stress

–Traditional gender role norms

–Poor family functioning

–Obsessive, controlling relationship

Geriatric Considerations

Factors associated with the abuse of older adults include increasing age, nonwhite race, low-income status, functional impairment, cognitive disability, substance use, poor emotional state, low self-esteem, cohabitation, and lack of social support.

Pediatric Considerations

Factors associated with child abuse or neglect include low-income status, low maternal education, nonwhite race, large family size, young maternal age, single-parent household, parental psychiatric disturbances, and presence of a stepfather.

DIAGNOSIS

DV is often underdiagnosed, with only 10–12% of physicians conducting routine screening.

Although prevalence of DV in primary care settings is 7–50%, <15% are screened.

Pregnancy increases risk.

Barriers to screening: time constraints, discomfort with the subject, fear of offending the patient, and lack of perceived skills and resources to manage DV

Abused patients may refuse to disclose abuse for many reasons, which include the following:

– Not feeling emotionally ready to admit the reality of the situation

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–Shame and self-blame

–Feelings of failure if abuse is admitted

–Fear of rejection by the physician

–Fear of retribution from abuser

–Belief that abuse will not happen again

–Belief that no alternatives or available resources exist

HISTORY

Physicians should introduce the subject of DV in a general way (i.e., “I routinely ask all patients about domestic violence. Have you ever been in a relationship where you were afraid?”).

How to screen

–Screen patient alone, without partner or others present.

–Ask screening questions in patient’s primary language; do not use children or other family members as interpreters.

Partner violence screen (sensitivity 35–71%; specificity 80–94%)

–“Have you ever been hit, kicked, punched, or otherwise, hurt by someone within the past year? If so, by whom?”

–“Do you feel safe in your current relationship?”

–“Is there a partner from a previous relationship who is making you feel unsafe now?”

CDC-recommended RADAR system

–R: Routinely screen every patient; make screening a part of everyday practice in prenatal, postnatal, routine gynecologic visits, and annual health screenings.

–A: Ask questions directly, kindly, and be nonjudgmental.

–D: Document findings in the patient’s chart using the patient’s own words, with details. Use body maps and photographs as necessary.

–A: Assess the patient’s safety and see if the patient has a safety plan.

–R: Review options for dealing with DV with the patient and provide referrals.

SAFE questions

–Stress/safety: “Do you feel safe in your relationship?”

–Afraid/abused: “Have you ever been in a relationship where you were threatened, hurt, or afraid?”

–Friends/family: “Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?”

–Emergency plan: “Do you have a safe place to go and the resources you need in an emergency?”

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HITS questions: “How often does your partner:

–Hurt you physically?

–Insult or talk down to you?

–Threaten you with harm?

–Scream or curse at you?”

Assess pregnancy difficulties such as poor/late prenatal care, low-birth-weight babies, and perinatal deaths.

Pelvic and abdominal pain, chronic without demonstrable pathology

Headaches, back pain

Gynecologic disorders

Sexually transmitted infections (STIs) including HIV/AIDS

Depression, suicidal ideation, anxiety, fatigue

Substance abuse

Eating disorders

Overuse of health services/frequent emergency room visits

Noncompliance

PHYSICALEXAM

Clinical presentation/psychological signs and symptoms

–Delay in seeking treatment

–Inconsistent explanation of injuries

–Reluctance to undress

–Signs of battered woman syndrome and/or posttraumatic stress disorder (PTSD) (flat affect/avoidance of eye contact, evasiveness, heightened startle response, sleep disturbance, traumatic flashbacks)

–Depression, anxiety, chronic fatigue, substance abuse

–Suspicious partner accompaniment at appointment; overly solicitous partner

and/or refusal to leave exam room Physical signs and symptoms

–Tympanic membrane rupture

–Rectal or genital injury (centrally located injuries with bathing-suit pattern of distribution—concealable by clothing)

–Head and neck injuries (site of 50% of abusive injuries)

–Facial scrapes, loose or broken tooth, bruises, cuts, or fractures to face or body

–Knife wounds, cigarette burns, bite marks, welts with outline of weapon (such as belt buckle)

–Broken bones

–Defensive posture injuries

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–Injuries inconsistent with the explanation given

–Injuries in various stages of healing

DIAGNOSTIC TESTS & INTERPRETATION

The U.S. Preventive Services Task Force (USPSTF) in 2013 issued guidelines recommending that clinicians screen all women of childbearing age (14 to 46 years old) for DV and provide or refer women to intervention services when appropriate (1)[B].

Other recommendations

–American College of Physicians (ACP) recommends routine screening for DV for all women in primary care settings at periodic intervals and when women present for emergency care with traumatic injuries.

–The American Medical Association (AMA) recommends that all patients be routinely screened for DV with inquiry into history of family violence.

–The World Health Organization (WHO) recommends against DV screening or routine inquiry about exposure to DV; however, they recommend asking about exposure to DV when assessing conditions that may be caused or complicated by abuse (2)[B].

–U.S. Surgeon General and American Association of Family Practitioners recommend that physicians consider the possibility of DV as a cause of illness and injury.

–The Partner Violence Screen is a three-question screening tool with a high specificity.

–There is no evidence of harm in screening for DV.

Pediatric Considerations

American Academy of Pediatrics (AAP) and AMArecommend that physicians remain alert for signs and symptoms of child physical and sexual abuse in the routine exam.

Pregnancy Considerations

American College of Obstetrics and Gynecologists (ACOG) and AMA guidelines on DV recommend that physicians routinely assess all pregnant women for DV. ACOG recommends periodic screening throughout obstetric care (at the first prenatal visit, at least once per trimester, at the postpartum checkup).

Initial Tests (lab, imaging)

Liver function tests (LFTs), amylase, lipase if abdominal trauma is suspected

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