Diverticulitis

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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
  • Diverticular bleeding (painless lower gastrointestinal bleeding) is NOT associated with diverticulitis

Clinical Features

Differential Diagnosis

LLQ Pain

Evaluation

Work-Up

  • Labs
    • CBC
    • Chemistry
    • LFTs
    • Lipase
    • Urinalysis
    • 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

Modified Hinchey Classification[2]

  • 0 Mild clinical diverticulitis
  • Ia Confined pericolic inflammation or phlegmon
  • Ib Pericolic or mesocolic abscess
  • II Pelvic, distant intraabdominal, or retroperitoneal abscess
  • III Generalized purulent peritonitis
  • IV Generalized fecal peritonitis

Management

Uncomplicated

  • Modified Hinchey Class 0
  • Liquid diet and bowel rest (low fiber foods) are most important

Antibiotic Options:

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.[5]

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:

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[6]

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

  1. ↑ 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.
  2. ↑ Wasvary H, Turfah F, Kadro O, et al. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65:632–635.
  3. ↑ Stollman N, Smalley W, and Hirano I. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015; 149(7):1944-1949.
  4. ↑ Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35
  5. ↑ 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
  6. ↑ 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.
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