Diverticulitis

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
  • Antibiotics should be used only for select patients and not routinely in acute uncomplicated diverticulitis[3]
  • Antibiotics are aimed at treating Gram Negative organisms and Anerobes (Enterobacteriaceae, Pseudomonas aeruginosa, Bacteriodes sp., and Enterococci)[4]

Uncomplicated

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]

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

Antibiotic Options:

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[8]

Discharge
  • Patients may be treated as outpatients if:[9]
    • Can tolerate PO
    • No significant comorbidities
    • Able to obtain outpatient antibiotics
    • Have adequate pain control
    • Have 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. Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
  7. Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
  8. 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.
  9. Friend K, Mills AM. Annals of EM. 2011.
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