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Diverticulitis

Introduction
Diverticulosis is the formation of abnormal pouches in the bowel wall, while diverticulitis is
inflammation or infection of these pouches. These conditions are known as diverticular
disease. Diverticulosis commonly starts presenting at around age 40 and increases as you get
older. Approximately 50% people >70 years have it.

History
Sharp abdominal pain, often LIF (70%) most diverticula occur in sigmoid colon

Fever

Abdo distension/bloating/flatulence

Change in bowel habits constipation/diarrhoea

Nausea/vomiting

Patient may have known diverticular disease.

Complications
Abscess

Obstruction

Perforation

Peritonitis

Haemorrhage

Fistula.

Examination
Simple diverticulitis, localised abdominal tenderness in the area of the affected
diverticula and fever

Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-
sided diverticulitis
Abscess formation - tender palpable mass

Peritonitis - generalised tenderness with rebound and guarding, abdomen may be


distended and tympanic to percussion, bowel sounds can be diminished or absent

Fistula - women with a colovaginal fistula may present with a purulent vaginal
discharge, colovesical fistula may present as urinary tract symptoms

PR should be performed

Elderly patients and some patients taking corticosteroids may have unremarkable
findings, even in the presence of severe diverticulitis.

Investigations

Staging
Clinical staging by Hinchey's classification is geared toward choosing the proper surgical
procedure when diverticulitis is complicated, as follows:

Stage I: Diverticulitis with phlegmon or localised pericolic or mesenteric abscess.

Stage II: Diverticulitis with walled-off pelvic, intra-abdominal, or retroperitoneal


abscess.

Stage III: Perforated diverticulitis causing generalised purulent peritonitis.

Stage IV: Rupture of diverticula into the peritoneal cavity with fecal contamination
causing generalised fecal peritonitis.

Management

Patient Factsheets
ECI ED Patient Factsheet - Diverticular Disease

References
Biondo, S. et al. (2014) Outpatient versus hospitalisation management for
uncomplicated diverticulitis: a prospective, multicenter randomised clinical trial
(DIVER Trial), Annals of Surgery, January 2014, vol. 259, no. 1, pp. 38-44.

Chabok, A. et al. (2012) Randomised clinical trial of antibiotics in acute


uncomplicated diverticulitis, British Journal of Surgery, April 2012, vol. 99, no. 4, pp.
532-539.

Isacson, D. et al. (2015) Outpatient, non-antibiotic management in acute


uncomplicated diverticulitis: a prospective study, International Journal of Colorectal
Disease, Epub ahead of print.

Makela, J.T. et al. (2015) The role of CRP in prediction of the severity of acute
diverticulitis in an emergency unit, Scandanavian Journal of Gastroenterology, vol.
50, no. 5, pp. 536-541.

ONeill, S. et al. (2011) Latest diagnosis and management of diverticulitis, British


Journal of Medical Practitioners, vol. 4, no. 4, a443.

Shahedi, K. et al. (2015) Diverticulitis, Medscape

Diverticulitis implications for practice - NICE guidelines


http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009092.pub2/full

eTG Therapeutic Guidelines, Diverticulitis

Practice Essentials
http://emedicine.medscape.com/article/173388-overview
Diverticular disease includes a spectrum of conditions ranging from asymptomatic
diverticular disease, to symptomatic uncomplicated diverticular disease, and complicated
diverticular disease that includes acute and chronic diverticulitis. Diverticulitis is defined as
an inflammation of one or more diverticula, which are small pouches created by the
herniation of the mucosa into the wall of the colon. Diverticulitis is generally considered a
disease of the elderly, but as many as 20% of patients with diverticulitis are younger than 50
years. In its chronic form, patients may have recurrent bouts of low-grade or overt
diverticulitis.

See Can't-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the
potentially life-threatening conditions that present with gastrointestinal symptoms.

Signs and symptoms


The clinical presentation of diverticulitis depends on the location of the affected diverticulum,
the severity of the inflammatory process, and the presence of complications. Presenting
complaints include the following:

Left lower quadrant pain (70% of patients)

Change in bowel habits

Nausea and vomiting

Constipation

Diarrhea

Flatulence

Bloating

Physical findings in patients with diverticulitis mirror the severity of the inflammation and
the presence of complications, as follows:

In simple diverticulitis, localized abdominal tenderness in the area of the affected


diverticula and fever

Left lower quadrant tenderness is most common, as most diverticula occur in the
sigmoid colon

Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-
sided diverticulitis

In complicated diverticulitis with abscess formation, a tender palpable mass

Elderly patients and some patients taking corticosteroids may have unremarkable
findings, even in the presence of severe diverticulitis

Findings in patients with peritonitis due to free perforation are as follows:

Generalized tenderness with rebound and guarding on abdominal examination

The abdomen may be distended and tympanic to percussion

Bowel sounds can be diminished or absent

If a fistula forms, the findings vary depending on the type of fistula, as follows:

Women with colovaginal fistulas may present with a purulent vaginal discharge

Colovesicular fistulas may present as urinary tract symptoms (eg, suprapubic, flank,
or costovertebral angle tenderness) or pneumaturia, and sometimes fecaluria
See Clinical Presentation for more detail.

Diagnosis

The diagnosis of acute diverticulitis can usually be made on the basis of history and physical
examination, but laboratory tests may be of help when the diagnosis is in question, as
follows:

The white blood cell count may show leukocytosis and a left shift, but may be normal
in immunocompromised, elderly, or less severely ill patients

A hemoglobin level is important in patients who report hematochezia

Electrolyte assays may be helpful in the patient who is vomiting or has diarrhea

Renal function is assessed prior to the administration of most intravenous contrast


material

Liver enzyme and lipase levels may help to exclude other causes of abdominal pain

Urinalysis may reveal red or white blood cells in patients with a colovesicular fistula
or with diverticulitis adjacent to the ureters or the bladder

A urine culture may distinguish sterile pyuria due to inflammation from polymicrobial
infection due to fistula

Blood cultures should be obtained prior to the administration of empiric parenteral


antimicrobial therapy in patients who are severely ill or in those with complicated
disease

A pregnancy test must be performed in any female of childbearing age with


abdominal pain

Computed tomography (CT) scanning of the abdomen is considered the best imaging method
to confirm the diagnosis. Sensitivity and specificity, especially with helical CT and colonic
contrast, can be as high as 97%. Possible CT findings include the following:

Pericolic fat stranding due to inflammation

Colonic diverticula

Bowel wall thickening

Soft-tissue inflammatory masses

Phlegmon

Abscesses
Other tests and procedures are as follows:

Contrast enema, using water-soluble medium, may be an option in mild-to-moderate


uncomplicated cases of diverticulitis when CT scans do not absolutely differentiate
between diverticulitis and colonic carcinoma

Plain abdominal radiograph series with supine and upright films can demonstrate
bowel obstruction or ileus; the presence of free air can indicate bowel perforation

Clinical staging by Hinchey's classification is geared toward choosing the proper surgical
procedure when diverticulitis is complicated, as follows:

Stage I: Diverticulitis with phlegmon or localized pericolic or mesenteric abscess

Stage II: Diverticulitis with walled-off pelvic, intra-abdominal, or retroperitoneal


abscess

Stage III: Perforated diverticulitis causing generalized purulent peritonitis

Stage IV: Rupture of diverticula into the peritoneal cavity with fecal contamination
causing generalized fecal peritonitis

See Workup for more detail.

Management

Patients with mild diverticulitis, typically with Hincheys stage I disease, can be treated with
the following outpatient regimen:

A clear liquid diet

7-10 days of oral broad-spectrum antimicrobial therapy

Patients can advance the diet slowly as tolerated after clinical improvement occurs,
which should be within 48-72 hours [1]

Single-agent or multiple-agent antibiotic regimens for outpatient therapy are equally


effective, provided that they provide both anaerobic and aerobic coverage. Potential regimens
include the following:

Ciprofloxacin and metronidazole

Trimethoprim-sulfamethoxazole and metronidazole

Moxifloxacin

Amoxicillin/clavulanic acid

Indications for hospital admission include the following:


Evidence of severe diverticulitis (eg, systemic signs of infection or peritonitis)

Inability to tolerate oral hydration

Failure of outpatient therapy (ie, persistent or increasing fever, pain, or leukocytosis


after 2-3 days)

Immunocompromise or significant comorbidities

Pain severe enough to require parenteral narcotic analgesia

Inpatient treatment is as follows:

Initiate bowel rest and intravenous fluid hydration

Start broad-spectrum intravenous antibiotic coverage until culture results, if obtained,


are available

Within 2-3 days of hospitalization, fever, pain, and leukocytosis should begin to
resolve

The patient can then be started on a clear liquid diet and advanced as tolerated

If tolerating oral intake and clinically stable, the patient can be discharged to complete
a 7- to 10-day course of an oral antibiotic therapy

Repeat the abdominal CT scan if patients do not show timely clinical improvement

CTguided percutaneous drainage is indicated for peridiverticular abscesses > 4 cm in


diameter

Monotherapy with beta-lactamase-inhibiting antibiotics or carbapenems is appropriate for


patients who are moderately ill and require admission. Such antibiotics include the following:

Piperacillin/tazobactam

Ampicillin/sulbactam

Ticarcillin/clavulanic acid

Imipenem

Meropenem

Tigecycline (when severe penicillin allergy is a concern)

Multiple-drug regimens may consist of metronidazole and a third-generation cephalosporin or


a fluoroquinolone, such as the following:
Ceftriaxone

Cefotaxime

Ciprofloxacin

Levofloxacin

Pain management considerations are as follows:

Morphine is preferred, despite theoretical risk of affecting bowel tone and sphincters

Meperidine is associated with adverse effects

Nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a


greater risk of colon perforation and should be avoided whenever possible

The classic surgical indications include some features characteristic of Hincheys stage III or
IV disease and are as follows:

Free-air perforation with fecal peritonitis

Suppurative peritonitis secondary to a ruptured abscess

Uncontrolled sepsis

Abdominal or pelvic abscess (unless CT-guided aspiration is possible)

Fistula formation

Inability to rule out carcinoma

Intestinal obstruction

Failing medical therapy

Immunocompromised status

Extremes of age

See Treatment and Medication for more detail.