Doctor123.org

Diverticulitis, Emergency Medicine

Basics

Description

- Left lower quadrant pain in 70% of cases in Western countries - Initially vague, then localizes - RLQ in 75% of Asian patients

- Peritoneal signs if: - Unremarkable exam if: - Elderly - Immunocompromised - Taking corticosteroids

- 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

- UA - Sterile pyuria is possible - Colonic flora (bacteria) suggests colovesical fistula

- Nondiagnostic criteria include: - Stricture - Diverticula - Fistula

- Endoscopy - Not necessary to diagnose acute illness - Rigid sigmoidoscopy aids in diagnosing nondiverticular causes of abdominal pain (spasm, stricture, edema, pus, or peridiverticular erythema).

- 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

- 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

- Analgesia - Anticholinergics (dicyclomine): - Reduces colonic spasm - Does not mask underlying pathology

- 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

- Peridiverticular abscess drainage: - Indicated if well circumscribed and easily accessible - Accomplished by CT- or ultrasound-guided percutaneous needle aspiration

  • Micro- or macroscopic perforation of diverticulumUncomplicated (75%) vs. complicated
  • Incidence increasing

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 thickeningInflammatory changes (fat stranding on CT)
  • Macroperforation: Complicated diverticulitis:AbscessBowel obstructionFistulas after recurrent attacksColovesical fistula (most common) presents with dysuria, frequency, urgency, pneumaturia, and fecaluria.Peritonitis

Diagnosis

Signs and Symptoms

History

  • Symptoms typically develop over daysAlmost 50% have had prior episodes of pain
  • Left lower quadrant pain in 70% of cases in Western countriesInitially vague, then localizesRLQ 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:
  • Unremarkable exam if:ElderlyImmunocompromisedTaking corticosteroids

Essential Workup

  • CBC
  • UA
  • Blood cultures and lactateIf showing signs of sepsis
  • CT of abdomen/pelvisPreferred diagnostic modalityAbility to diagnose nondiverticular causes of abdominal painAccuracy enhanced with use of IV and PO/PR contrastGastrografin PO/PR (per rectum) contrast may be used; avoid barium, especially when perforation is suspected
  • Plain radiographs: Chest/abdomen

Diagnosis Tests & Interpretation

Lab

  • CBCLeukocytosis common, but absence does not exclude diagnosis
  • UASterile pyuria is possibleColonic flora (bacteria) suggests colovesical fistula

Imaging

  • Abdominal (supine and upright) and chest radiographsPerforation indicated by free airObstruction indicated by air-fluid levels
  • CTDiagnostic criteria include:Wall thickening >5 mmInflammation of pericolic fatPericolic abscessNondiagnostic criteria include:StrictureDiverticulaFistulaCT-guided percutaneous needle aspiration of localized abscesses avoids further surgery.
  • EndoscopyNot necessary to diagnose acute illnessRigid sigmoidoscopy aids in diagnosing nondiverticular causes of abdominal pain (spasm, stricture, edema, pus, or peridiverticular erythema).
  • USFor diagnosing colonic wall thickening, inflammation, mass, abscess, or fistulaGreatly operator dependentNot reliable in presence of intestinal gas
  • Barium enemaIndicated 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
  • AppendicitisLeft-sided pain if peritonitis from ruptured appendixRight-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 restNPO or clear liquid dietNasogastric tube (NG) tube if persistent vomiting or bowel obstruction suspected

Ed Treatment/Procedures

  • Uncomplicated diverticulitisMost respond to medical therapy, but 30% may require surgery
  • Complicated diverticulitisMost require percutaneous drainage or surgery
  • AnalgesiaAnticholinergics (dicyclomine):Reduces colonic spasmDoes not mask underlying pathologyOpiates 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 clindamycinTrimethoprim/sulfamethoxazole (TMP/SMX) DS + metronidazoleAmoxicillin/clavulanateDuration of therapy is 10-14 daysModerate uncomplicated and mild complicated cases for inpatient management:Ceftriaxone or other 3rd-generation cephalosporin + metronidazole or clindamycinAmpicillin/sulbactamPiperacillin/tazobactamTicarcillin/clavulanateCiprofloxacin or levaquin + metronidazole or clindamycinAztreonamComplicated cases (with peritonitis from perforation), consider:Imipenem/cilastatinMeropenemAztreonam + metronidazole or clindamycinGentamicin + metronidazole or clindamycin ± ampicillinTrovafloxacin (alternative)
  • Surgery:Emergent surgery:Indicated for generalized peritonitis from perforation2-stage procedure with resection of diseased segment of colon and proximal colostomy followed later with reanastomosisElective 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 therapyNonoperative management may be considered for complicated diverticulitis.Peridiverticular abscess drainage:Indicated if well circumscribed and easily accessibleAccomplished by CT- or ultrasound-guided percutaneous needle aspiration
  • Outpatient therapy:Clear liquids with follow-up in 2-3 daysWhen 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 daysAmoxicillin-clavulanate 875/125 mg PO BIDTrimethoprim/sulfamethoxazole DS 1 tablet PO BID AND metronidazole 500 mg PO q6hCiprofloxacin 500 mg PO BID AND metronidazole 500 mg PO q8hFor patients intolerant of metronidazole, consider clindamycin
  • Complicated diverticulitisTicarcillin/clavulanate: 3.1 g IV q6h orAmpicillin/sulbactam: 3 g IV q6h orCeftriaxone 1 g IV q24h AND metronidazole 500 mg IV q8hLevofloxacin 500 mg or 750 mg IV q24h (or ciprofloxacin 400 mg IV q12h) AND metronidazole 1 g IV q12hImipenem 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 diseaseMultiple attacks do not seem to lead to increased complications.
  • Diverticulitis does not seem to be a progressively worsening processAcute episodes can present at any stage.
  • Severe disease on initial CT scanIncreased risk of failure of medical therapyHigh 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)