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Diverticulitis, Emergency Medicine


Basics


Description


  • Micro- or macroscopic perforation of diverticulum

    • Uncomplicated (75%) vs. complicated

  • Incidence increasing

    • Obesity is a risk factor


Etiology


  • Fecal material in diverticulum hardens, forming fecalith, increasing intraluminal pressure

  • Erosion of diverticular wall leads to inflammation

  • Focal necrosis leads to perforation

  • Microperforation: Uncomplicated diverticulitis:

    • Colonic wall thickening

    • Inflammatory changes (fat stranding on CT)

  • Macroperforation: Complicated diverticulitis:

    • Abscess

    • Bowel obstruction

    • Fistulas after recurrent attacks

    • Colovesical fistula (most common) presents with dysuria, frequency, urgency, pneumaturia, and fecaluria.

    • Peritonitis


Diagnosis


Signs and Symptoms


History
  • Symptoms typically develop over days

    • Almost 50% have had prior episodes of pain

  • Left lower quadrant pain in 70% of cases in Western countries

    • Initially vague, then localizes

    • RLQ in 75% of Asian patients

  • Nausea/vomiting, constipation, diarrhea, urinary symptoms (in decreasing order)


Physical Exam
  • +/- low-grade fever

  • Tenderness at left lower quadrant with occasional (20%) mass palpated (phlegmon):

    • Phlegmon-inflamed bowel loops or abscess

  • Abdominal distension

  • Bowel sounds variable

  • Rectal tenderness with heme-positive stool:

    • Massive gross rectal bleeding (rare)

  • Peritoneal signs if:

    • Perforation has occurred

  • Unremarkable exam if:

    • Elderly

    • Immunocompromised

    • Taking corticosteroids


Essential Workup


  • CBC

  • UA

  • Blood cultures and lactate

    • If showing signs of sepsis

  • CT of abdomen/pelvis

    • Preferred diagnostic modality

    • Ability to diagnose nondiverticular causes of abdominal pain

    • Accuracy enhanced with use of IV and PO/PR contrast

    • Gastrografin PO/PR (per rectum) contrast may be used; avoid barium, especially when perforation is suspected

  • Plain radiographs: Chest/abdomen


Diagnosis Tests & Interpretation


Lab
  • CBC

    • Leukocytosis common, but absence does not exclude diagnosis

  • UA

    • Sterile pyuria is possible

    • Colonic flora (bacteria) suggests colovesical fistula


Imaging
  • Abdominal (supine and upright) and chest radiographs

    • Perforation indicated by free air

    • Obstruction indicated by air-fluid levels

  • CT

    • Diagnostic criteria include:

      • Wall thickening >5 mm

      • Inflammation of pericolic fat

      • Pericolic abscess

    • Nondiagnostic criteria include:

      • Stricture

      • Diverticula

      • Fistula

    • CT-guided percutaneous needle aspiration of localized abscesses avoids further surgery.

  • Endoscopy

    • Not necessary to diagnose acute illness

    • Rigid sigmoidoscopy aids in diagnosing nondiverticular causes of abdominal pain (spasm, stricture, edema, pus, or peridiverticular erythema).

  • US

    • For diagnosing colonic wall thickening, inflammation, mass, abscess, or fistula

    • Greatly operator dependent

    • Not reliable in presence of intestinal gas

  • Barium enema

    • Indicated after resolution of acute illness to rule out fistula or other colonic pathology (e.g., carcinoma)


Differential Diagnosis


  • Colon carcinoma with perforation

  • Ischemic colitis

  • Bacterial colitis

  • Appendicitis

    • Left-sided pain if peritonitis from ruptured appendix

    • Right-sided diverticular pain with cecal diverticulum (rare) or redundant sigmoid colon

  • Inflammatory bowel disease

  • Irritable bowel syndrome

  • Ruptured or torsed ovarian cyst

  • Pancreatic disease

  • Pelvic inflammatory disease

  • Peptic ulcer disease

  • Renal colic


Treatment


Pre-Hospital


IV fluids  

Initial Stabilization/Therapy


  • Fluid resuscitation with 0.9% normal saline

  • Bowel rest

    • NPO or clear liquid diet

    • Nasogastric tube (NG) tube if persistent vomiting or bowel obstruction suspected


Ed Treatment/Procedures


  • Uncomplicated diverticulitis

    • Most respond to medical therapy, but 30% may require surgery

  • Complicated diverticulitis

    • Most require percutaneous drainage or surgery

  • Analgesia

    • Anticholinergics (dicyclomine):

      • Reduces colonic spasm

      • Does not mask underlying pathology

    • Opiates for more aggressive pain management (theoretically increase intraluminal pressure, leading to perforation)

      • Do not use if hemodynamically unstable

  • Antibiotics to cover gram-negative aerobic and anaerobic bacteria:

    • Mild, uncomplicated cases (peridiverticulitis) for outpatient management:

      • Ciprofloxacin or levaquin + metronidazole or clindamycin

      • Trimethoprim/sulfamethoxazole (TMP/SMX) DS + metronidazole

      • Amoxicillin/clavulanate

      • Duration of therapy is 10-14 days

    • Moderate uncomplicated and mild complicated cases for inpatient management:

      • Ceftriaxone or other 3rd-generation cephalosporin + metronidazole or clindamycin

      • Ampicillin/sulbactam

      • Piperacillin/tazobactam

      • Ticarcillin/clavulanate

      • Ciprofloxacin or levaquin + metronidazole or clindamycin

      • Aztreonam

    • Complicated cases (with peritonitis from perforation), consider:

      • Imipenem/cilastatin

      • Meropenem

      • Aztreonam + metronidazole or clindamycin

      • Gentamicin + metronidazole or clindamycin ± ampicillin

      • Trovafloxacin (alternative)

  • Surgery:

    • Emergent surgery:

      • Indicated for generalized peritonitis from perforation

      • 2-stage procedure with resection of diseased segment of colon and proximal colostomy followed later with reanastomosis

    • Elective surgery:

      • Indicated for multiple recurrent attacks (>2) without generalized peritonitis (controversial); fistula formation; intractable pain; unresolved obstruction; failure of medical therapy; single serious attack in patient <50 yr of age (controversial)

      • 1-stage procedure following resolution of inflammation from medical therapy

      • Nonoperative management may be considered for complicated diverticulitis.

    • Peridiverticular abscess drainage:

      • Indicated if well circumscribed and easily accessible

      • Accomplished by CT- or ultrasound-guided percutaneous needle aspiration

  • Outpatient therapy:

    • Clear liquids with follow-up in 2-3 days

    • When acute condition has resolved:

      • High-fiber, low-fat diet to decrease recurrence of attacks


Medication


  • Amoxicillin/clavulanate: 500/125 mg PO TID or 875/125 mg PO BID

  • Ampicillin: 2 g IV q6h

  • Ampicillin/sulbactam: 3 g IV q6h

  • Cefotetan: 2 g IV q12h

  • Cefoxitin: 2 g IV q8h

  • Ciprofloxacin: 400 mg IV q12h or 500 mg PO BID

  • Dicyclomine: 20 mg PO QID (up to 40 mg PO QID) or 20 mg IM q6h (not for IV use)

  • Gentamicin: Multiple daily dose (MDD) regimen, 2 mg/kg load, then 1.7 mg/kg IV q8h, or once-daily dose (OD) regimen, 5-7 mg/kg IV q24h (assuming normal renal function)

  • Imipenem/cilastatin: 500 mg IV q6h

  • Meropenem: 1 g IV q8h

  • Metronidazole: 1 g (15 mg/kg) IV load then 500 mg IV q8h or 500 mg PO q8h

  • Piperacillin/tazobactam: 3.375 g IV q6h or 4.5 g IV q8h

  • Ticarcillin/clavulanate: 3.1 g IV q6h

  • Trimethoprim/sulfamethoxazole DS: 1 tablet PO BID

  • Trovafloxacin: 300 mg IV for 1st dose, then 200 mg IV/PO daily


First Line
  • Uncomplicated diverticulitis (outpatient), 10-14 days

    • Amoxicillin-clavulanate 875/125 mg PO BID

    • Trimethoprim/sulfamethoxazole DS 1 tablet PO BID AND metronidazole 500 mg PO q6h

    • Ciprofloxacin 500 mg PO BID AND metronidazole 500 mg PO q8h

    • For patients intolerant of metronidazole, consider clindamycin

  • Complicated diverticulitis

    • Ticarcillin/clavulanate: 3.1 g IV q6h or

    • Ampicillin/sulbactam: 3 g IV q6h or

    • Ceftriaxone 1 g IV q24h AND metronidazole 500 mg IV q8h

    • Levofloxacin 500 mg or 750 mg IV q24h (or ciprofloxacin 400 mg IV q12h) AND metronidazole 1 g IV q12h

    • Imipenem 500 mg IV q6h or meropenem 1 g IV q8h


Follow-Up


Disposition


Admission Criteria
  • Intractable pain and/or vomiting

  • High fever

  • Peritonitis

  • Failure to respond to outpatient management

  • Severe disease on CT scan

  • Significant leukocytosis

  • Immunocompromised or steroid-dependent patients

  • Recurrent episodes

  • Comorbidities: Renal insufficiency, liver dysfunction, COPD, diabetes with end-organ damage

  • Extremes of age

  • Uncertainty of diagnosis


Discharge Criteria
  • Mild cases (low-grade fever, mild discomfort) of known diverticular disease

  • Minimal comorbidities

  • Tolerating PO


Issues for Referral
Massive diverticular bleeding requiring GI or surgical consultation  

Follow-Up Recommendations


  • Clear liquids

  • Clinical improvement should be seen in 3 days, after which diet can be advanced

  • Advise patients to call for increasing pain, fever, or inability to tolerate PO

  • Colonoscopy (or contrast enema x-ray with flexible sigmoidoscopy) should be obtained after resolution of initial episode

  • Patients do NOT need to avoid seeds and nuts


Pearls and Pitfalls


  • CT scanning differentiates diverticulitis as complicated or uncomplicated:

    • Surgery reserved for complicated cases, but nonoperative management becoming more prevalent

  • Most cases of uncomplicated diverticulitis rarely progress to complicated disease

    • Multiple attacks do not seem to lead to increased complications.

  • Diverticulitis does not seem to be a progressively worsening process

    • Acute episodes can present at any stage.

  • Severe disease on initial CT scan

    • Increased risk of failure of medical therapy

    • High risk of secondary complications


Additional Reading


  • Lorimer  JW, Doumit  G. Comorbidity is a major determinant of severity in acute diverticulitis. Am J Surg.  2007;193:681-685.

  • Nelson  RS, Ewing  BM, Wengert  TJ, et al. Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg.  2008;196(6):969-972.

  • Rafferty  J, Shellito  P, Hyman  NH, et al.; Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum.  2006;49:939-944.

  • Stollman  NH, Raskin  JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol.  1999;94:3110-3121.

  • Touzios  JG, Dozois  EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am.  2009;38(3):513-525.

  • Yoo  PS, Garg  R, Salamone  LF, et al. Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg.  2008;196:710-714.


See Also (Topic, Algorithm, Electronic Media Element)


Diverticulosis  

Codes


ICD9


  • 562.11 Diverticulitis of colon (without mention of hemorrhage)

  • 562.13 Diverticulitis of colon with hemorrhage


ICD10


  • K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding

  • K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding

  • K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding

  • K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding

  • K57.2 Diverticulitis of large intestine with perforation and abscess

  • K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding

  • K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding

  • K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding

  • K57.8 Diverticulitis of intestine, part unspecified, with perforation and abscess


SNOMED


  • 307496006 Diverticulitis (disorder)

  • 4494009 Diverticulitis of large intestine

  • 235774002 Colonic diverticular abscess (disorder)

  • 76953007 Diverticulitis of colon with perforation (disorder)

  • 430347001 Diverticulitis of cecum (disorder)

  • 430877000 Diverticulitis of rectum (disorder)

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