Diverticulitis

Diverticulitis diagnosis and treatment

Diverticulitis

Diverticulitis is defined as macroscopic inflammation of a diverticulum that may reflect a spectrum from inflamma­tion alone, to microperforation with localized paracolic inflammation, to macroperforation with either abscess or generalized peritonitis. Thus, there is a range from mild to severe disease.

Most patients with localized inflammation or infection report mild to moderate aching abdominal pain, usually in the left lower quadrant.

Constipation or loose stools may be present. Nausea and vomiting are fre­quent.

In many cases, symptoms are so mild that the patient may not seek medical attention until several days after onset.

Physical findings include a low-grade fever, left lower quadrant tenderness, and a palpable mass.

Stool occult blood is common, but hematochezia is rare.

Leuko­cytosis is mild to moderate. Patients with free perforation present with a more dramatic picture of generalized abdominal pain and peritoneal signs.

Differential Diagnosis

Diverticulitis must be distinguished from other causes of lower abdominal pain, including perforated colonic car­cinoma, Crohn disease, appendicitis, ischemic colitis, C difficile–associated colitis, and gynecologic disorders (ectopic pregnancy, ovarian cyst or torsion) by abdominal CT scan, pelvic ultrasonography, or radiographic studies of the distal colon that use water-soluble contrast enemas.

Two 2017 prospective cohort studies reported a lower risk of diverticulitis in men consuming diets high in fruits, vegetables, and whole grains than diets high in red meat and refined grains.

Treatment

A. Medical Management

Most patients can be managed with conservative measures. Patients with mild symptoms and no peritoneal signs may be managed initially as outpatients on a clear liquid diet. Although broad-spectrum oral antibiotics with anaerobic activity commonly are prescribed, large clinical trials con­firm that antibiotics are not beneficial in uncomplicated disease.

A 2015 American Gastroenterological Association guideline suggests that antibiotics should be used selectively for uncomplicated disease. Reasonable regimens include amoxicillin and clavulanate potassium (875 mg/125 mg) twice daily; or metronidazole, 500 mg three times daily; plus either ciprofloxacin, 500 mg twice daily, or trimethoprim-sulfamethoxazole, 160/800 mg twice daily orally, for 7–10 days or until the patient is afebrile for 3–5 days.

Symptomatic improvement usually occurs within 3 days, at which time the diet may be advanced. Once the acute epi­sode has resolved, a high-fiber diet is often recommended. Patients with increasing pain, fever, or inability to tolerate oral fluids require hospitalization. Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and patients who are elderly or immunosuppressed or who have serious comorbid disease require hospitalization acutely. Patients should be given nothing by mouth and should receive intravenous fluids. If ileus is present, a naso­gastric tube should be placed.

Intravenous antibiotics should be given to cover anaerobic and gram-negative bacteria. Single-agent therapy with either a second-generation cepha­losporin (eg, cefoxitin), piperacillin-tazobactam, or ticarcillin clavulanate appears to be as effective as combination therapy (eg, metronidazole or clindamycin plus an aminoglycoside or third-generation cephalosporin [eg, ceftazidime, cefo­taxime]). Symptomatic improvement should be evident within 2–3 days. Intravenous antibiotics should be continued for 5–7 days, before changing to oral antibiotics.

B. Surgical Management

Surgical consultation and repeat abdominal CT imaging should be obtained on all patients with severe disease or those who do not improve after 72 hours of medical man­agement. Patients with a localized abdominal abscess 4 cm in size or larger are usually treated urgently with a percuta­neous catheter drain placed by an interventional radiologist. This permits control of the infection and resolution of the immediate infectious inflammatory process. In this man­ner, a subsequent elective one-stage surgical operation can be performed (if deemed necessary) in which the diseased segment of colon is removed and primary colonic anastomosis performed. After recovery, the decision to perform elective surgery depends on the patient’s age, comorbid disease, and frequency and severity of attacks. Patients with chronic disease resulting in fistulas or colonic obstruction will require elective surgical resection.

Indications for emergent surgical management include generalized peritonitis, large undrainable abscesses, and clinical deterioration despite medical management and percutaneous drainage. Surgery may be performed in one-or two-stage operations depending on the patient’s nutri­tional status, severity of illness, and extent of intra-abdominal peritonitis and abscess formation.

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