Diverticulitis

Background

• Prevalence of diverticulosis 30% by age 60, >70% by age 85
• 70% of pts w/ diverticulosis remain asymptomatic
• Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Asia)
• Pathogenesis
  • Erosion of diverticular wall by inspissated fecal material leads to microperforation
    • Most common pathogens are anaerobes, as well as gram-negative rods
• Diverticular bleeding (painless LGIB) is NOT associated w/ diverticulitis

Clinical Features

• LLQ abdominal pain
  • Asian pt may c/o RLQ or suprapubic pain
• Fever
• Leukocytosis
• Change in bowel habits: diarrhea (30%) or constipation (50%)
• N/V
• Anorexia

DDX

1. Appendicitis
2. Colitis—ischemic or infectious
3. Inflammatory bowel disease (Crohn disease, ulcerative colitis)
4. Colon cancer
5. Irritable bowel syndrome
6. Pseudomembranous colitis
7. Epiploic appendagitis
8. Gallbladder disease
9. Incarcerated hernia
10. Mesenteric infarction
11. Complicated ulcer disease
12. Peritonitis
13. Obstruction
14. Ovarian torsion
15. Ectopic pregnancy
16. Ovarian cyst or mass
17. Pelvic inflammatory disease
18. Cystitis
19. Kidney stone
20. Renal pathology
21. Pancreatic disease

Diagnosis

• Stable pt w/ h/o confirmed diverticulitis does not require further diagnostic evaluation
  • 1st time episode or current episode different from previous requires diagnostic imaging

Work-Up

1. Labs
   1. CBC
   2. Chemistry
   3. LFTs
   4. Lipase
   5. UA
2. Imaging
   1. CT w/ IV and PO contrast
      1. Sn 97%, Sp 100%

Treatment

• Antibiotics are aimed at treating Gram Negative organisms and Anerobes (Enterobacteriaceae, Pseudomonas aeruginosa, Bacteriodes sp., and Enterococci)

Uncomplicated

• Liquid diet and bowel rest are most important

Antibiotic Options:

• Metronidazole 500mg PO Q8hrs AND Ciprofloxacin 500mg PO BID x5days
• Amoxicillin/Clavulanate 875/125 PO Q8hrs x5days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])
• Trimethoprim/Sulfamethoxazole, one double-strength tablet bid, and Metronidazole 500 mg Q8h
• Moxifloxacin 400mg PO QDaily

Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient receives sufficient bowel rest in coordination with medicine observation and close follow up.

Complicated

• Defined as having a phlegmon, abscess, stricture, obstruction, fistula, or perforation
• Bowel rest in coordination with antibiotics
• Surgical consult for drainage of abscess or further surgical intervention

Antibiotics Options:

• Ticarcillin/Clavulanate 3.1 g IV Q6h or
• Piperacillin/Tazobactam 3.375 g IV q6 hours x 7-10 days
• Ciprofloxacin 400 mg IV q12h and metronidazole 1 g IV Q12h
• Ampicillin 2 g IV Q6h and Metronidazole 500 mg IV q6h Plus (Gentamicin 7 mg/kg Q24h or Ciprofloxacin 400 mg IV Q12h)
• Imipenem 500 mg IV Q6h

Disposition

1. Admit
   1. All complicated diverticulitis
   2. Intractable N/V, comborbid disease, high WBC, high fever, elderly, immunocompromised
   3. Failed outpt therapy (worsening symptoms or CT findings w/in 6wk of initial episode)
2. Discharge
   1. Well-appearing, immunocompetent pts w/ uncomplicated disease
   2. Refer all newly-diagnosed pts for f/u colonoscopy in 6 wk (CT cannot r/o carcinoma)
   3. Surgical referral should be made for all pts w/ 2nd episode of diverticulitis

Source

Tintinalli