Gastroenterology Book

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Diverticulitis

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  1. See Also
    1. Diverticulosis
  2. Pathophysiology
    1. Complicates 5% of Diverticulosis
    2. Distribution
      1. Most often affects sigmoid colon
      2. Right Diverticular Disease in age <60 and asians
    3. Inflammation of colonic Diverticula
      1. Impacted with fecal material (fecalith)
      2. Colon Perforation
        1. Microperforation (Simple Diverticulitis)
          1. Peridiverticulitis with localized phlegmon
          2. Infection walled off by pericolic fat
        2. Macroperforation (Complicated Diverticulitis)
          1. Pericolic abscess or
          2. Free perforation with generalized peritonitis
          3. Fistulas may form between adjacent structures
  3. Symptoms
    1. Mild anorexia
    2. Nausea or Vomiting
    3. Chills
    4. Diarrhea or obstipation
    5. Abdominal Pain: Acute constant pain
      1. Initial: Hypogastric pain
      2. Later: Left Lower Quadrant Abdominal Pain (>92%)
  4. Signs
    1. Fever
    2. Tenderness over left lower quadrant
    3. Guarding and rebound tenderness may be present
  5. Labs
    1. Complete Blood Count
      1. Leukocytosis (>68% of cases)
    2. Urinalysis
      1. Dysuria and urinary frequency may occur
  6. Radiology
    1. Abdominal flat and upright abdomen
      1. Observe for abdominal free air
      2. Small Bowel Obstruction
    2. Abdominal CT with contrast
      1. Best test to confirm Diverticulitis
      2. Best test to identify complications (perforation)
      3. Findings suggestive of perforation
        1. Pericolic fat infiltration
        2. Fascial thickening and muscle hypertrophy
        3. Arrowhead sign
          1. Localized bowel wall thickening
          2. Bowel lumen resembles arrow shape at diverticulum
    3. Avoid Colonoscopy in acute disease
      1. Risk of worsening perforation
    4. Avoid Barium Enema in acute disease
      1. Risk of extravasation if perforation
  7. Management: General Measures
    1. Clear Liquid Diet (NPO in severe disease)
    2. Low fiber diet in acute phase
    3. Avoid Narcotics (increases intracolonic pressure)
      1. Except Meperidine (decreases intraluminal pressure)
    4. Anticipate improvement within 48-72 hours
  8. Management: Outpatient Mangement of mild disease
    1. Indications for outpatient management
      1. Uncomplicated Diverticulitis
      2. Stable clinically
      3. Tolerating oral fluids
    2. Antibiotic regimen
      1. Primary protocol (requires 2 agents for 7-10 days)
        1. Ciprofloxacin 500 mg PO bid or Septra DS PO bid and
        2. Metronidazole (Flagyl) 500 mg PO q6 hours
      2. Alternative protocol
        1. Augmentin 500 mg PO tid for 7-10 days
  9. Management: Inpatient
    1. Indications for hospitalization
      1. Age >85 years
      2. Significant inflammation
      3. Unable to take oral fluids
    2. General measures
      1. Nothing by mouth initially
    3. Antibiotic regimen for moderate disease
      1. Primary agents
        1. Unasyn 3 g IV q6 hours
        2. Zosyn 3.375 g IV q6 hours
        3. Timentin 3.1 g IV q6 hours
      2. Alternative agents
        1. Cefoxitin 2 g IV q8 hours
        2. Cefotetan 2 g IV q12 hours
        3. Ciprofloxacin 400 mg IV q12h with Flagyl 500 IV q6h
    4. Antibiotic regimen for severe disease (e.g. ICU)
      1. Primary agents
        1. Imipenem 500 mg IV q6 hours or
        2. Merepenem 1 g IV q8 hours
      2. Alternative agents
        1. Trovafloxacin 300 mg IV day 1, then 200 mg IV qd or
        2. Three agent protocol 1
          1. Ampicillin 2 g IV q6 hours and
          2. Metronidazole 500 mg IV q6 hours and
          3. Aminoglycoside (requires monitoring of levels)
            1. Gentamicin or
            2. Tobramycin or
            3. Amikacin
        3. Three agent protocol 2
          1. Ampicillin 2 g IV q6 hours and
          2. Metronidazole 500 mg IV q6 hours
          3. Ciprofloxacin 400 mg IV q12 hours
  10. Course
    1. Improves on antibiotics within 48 to 72 hours
  11. Follow-up
    1. Colonoscopy 6 weeks after Diverticulitis episode
      1. Define extent of Diverticulosis
      2. Evaluate for Colon Cancer
      3. Barium Enema may be used as alternative option
    2. Surgical indications
      1. Recurrent Diverticulitis (more than 1 episode)
  12. Complications
    1. Colonic perforation
    2. Colonic abscess
    3. Generalized peritonitis
    4. Colonic fistula
  13. Prevention
    1. High fiber diet (except in acute phase - see above)
    2. Maintain adequate hydration
  14. Prognosis
    1. After first episode, recurs in 20-30% of cases
    2. After second episode, recurs in 50% of cases
  15. References
    1. Gilbert (2002) Sanford Guide to Antimicrobials, p. 14
    2. Simmang in Feldman (1998) Gastrointestinal, p. 1793-7
    3. Salzman (2005) Am Fam Physician 72:1229

Diverticulitis (C0012813)

Definition (MSH)Inflammation of a DIVERTICULUM or diverticula.
ConceptsDisease or Syndrome (T047)
ICD9562.11
MSHD004238
EnglishDiverticulitides, Diverticulitis, Diverticulitis unspecified
Spanishdiverticulitis, diverticulitis no especificada
Parent ConceptsDiverticulosis and diverticulitis (C0810029), Pathologic Processes (C0030660), Non-Neoplastic Gastrointestinal Disorder (C1335011), Diverticulitis (C0012813), diverticulum (C0012817), Inflammation (C0021368), Inflammatory disorder (C1290884), Duplicate concept (C1274013)
SourcesCCS, COSTAR, CST, DXP, LCH, MSH, MTH, MTHICD9, NCI, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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