Diverticulitis
Revision as of 14:04, 6 August 2016 by Rossdonaldson1 (talk | contribs) (Text replacement - "LGIB" to "lower gastrointestinal bleeding")
Background
- Prevalence of diverticulosis 30% by age 60, >70% by age 85
- 70% of patients with diverticulosis remain asymptomatic
- 13% of diverticulitis is found in patients <40 yrs of age[1]
- 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
- Erosion of diverticular wall by inspissated fecal material leads to microperforation
- Diverticular bleeding (painless lower gastrointestinal bleeding) is NOT associated with diverticulitis
Clinical Features
- LLQ abdominal pain
- Asian patients may complain of RLQ or suprapubic pain
- Fever
- Leukocytosis
- Change in bowel habits: diarrhea (30%) or constipation (50%)
- Nausea/vomiting
- Anorexia
Differential Diagnosis
LLQ Pain
- Diverticulitis
- Kidney stone
- UTI
- Pyelonephritis
- Ectopic pregnancy
- Infectious colitis
- Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
- Inguinal hernia
- Mesenteric ischemia
- Epiploic appendagitis
- Mittelschmerz
- Ovarian cyst
- Ovarian torsion
- PID
- Psoas abscess
- Testicular torsion
- Appendicitis
- Abdominal aortic aneurysm
- Herpes zoster
- Endometriosis
- Colon cancer
- Irritable bowel syndrome
- Small bowel obstruction
Evaluation
Work-Up
- Labs
- CBC
- Chemistry
- LFTs
- Lipase
- UA
- CT with IV and PO contrast (Sn 97%, Sp 100%)
- Pericolic stranding
- Bowel wall thickening
- Wall enhancement (inner and outer high attenuation layers)
- Perforation - extravasation of air/fluid
- Abscess in 30% with fluid and/or gas
- Bladder fistula
Evaluation
- Stable patient with history of confirmed diverticulitis does not require further diagnostic evaluation
- 1st time episode or current episode different from previous requires diagnostic imaging
Management
- Antibiotics should be used only for select patients and not routinely in acute uncomplicated diverticulitis[2]
- Antibiotics are aimed at treating Gram Negative organisms and Anerobes (Enterobacteriaceae, Pseudomonas aeruginosa, Bacteriodes sp., and Enterococci)[3]
Uncomplicated
- Modified Hinchey Class 0
- Liquid diet and bowel rest (low fiber foods) are most important
Antibiotic First, consider whether antibiotics are needed:
- In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[4][5]
- Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[4]
If antibiotics are prescribed (4-7 day course preferred):[4]
Preferred:
- Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[6][7]
- Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[7]
- Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[8]
Alternatives (penicillin allergy or intolerance):
- Trimethoprim/Sulfamethoxazole one double-strength tablet BID PLUS Metronidazole 500mg PO Q8h x 5 days
- Metronidazole 500mg PO Q8hrs PLUS Ciprofloxacin 500mg PO BID x 5 days (reserve for patients without non-fluoroquinolone options)[8]
- Moxifloxacin 400mg PO QDaily (same fluoroquinolone cautions apply)[9]
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.[10]
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
- Hinchey Stages I-IV
- 1a - phlegmon
- 1b - pericolic or mesenteric abscess
- 2 - walled off abscess
- 3 - purulent peritonitis
- 4 - fecal peritonitis
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/Cilastatin 500 mg IV Q6h
Disposition
Admit
- All complicated diverticulitis
- Intractable nausea/vomiting
- Comborbid disease
- High WBC, high fever, elderly, immunocompromised
- Failed outpatient therapy (worsening symptoms or CT findings within 6 weeks of initial episode)
- Large abscess > 3-4cm requiring percutaneous drainage with CT or US[11]
Discharge
- Well-appearing, immunocompetent patients with uncomplicated disease
- Refer all newly-diagnosed patients for follow up colonoscopy in 6 weeks (CT cannot rule out carcinoma)
- Surgical referral should be made for all patients with 3rd episode of diverticulitis
See Also
References
- ↑ Schneider EB, et al. Emergency department presentation, admission, and surgical intervention for colonic diverticulitis in the United States. American Journal of Surgery. April 29, 2015.
- ↑ Stollman N, Smalley W, and Hirano I. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015; 149(7):1944-1949.
- ↑ Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35
- ↑ 4.0 4.1 4.2 Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059
- ↑ Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
- ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
- ↑ 7.0 7.1 Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315
- ↑ 8.0 8.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
- ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
- ↑ Chabok A. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688
- ↑ Siewert B et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol. 2006 Mar;186(3):680-6.