5. Diverticulitis
4. Signs
1. See Also 1. Fever
1. Diverticulosis 2. Tenderness over left lower quadrant
3. GUARDING AND REBOUND TENDERNESS MAY BE
PRESENT
2. Pathophysiology
1. COMPLICATES 5% OF DIVERTICULOSIS
5. Labs
2. DISTRIBUTION 1. COMPLETE BLOOD COUNT
1. MOST OFTEN AFFECTS SIGMOID COLON 1. Leukocytosis (>68% of cases)
2. Right Diverticular Disease in age <60 and
asians
2. URINALYSIS
1. DYSURIA AND URINARY
FREQUENCY MAY OCCUR
3. INFLAMMATION OF COLONIC DIVERTICULA
1. Impacted with fecal material
(fecalith)
6. Radiology
1. ABDOMINAL FLAT AND UPRIGHT
ABDOMEN
2. Colon Perforation 1. Observe for abdominal free air
1. Microperforation 2. Small Bowel Obstruction
(Simple Diverticulitis)
1. Peridiverticulitis with
localized phlegmon
2. Infection walled off by
pericolic fat
2. ABDOMINAL CT WITH CONTRAST
1. Best test to confirm Diverticulitis
2. Macroperforation
(Complicated Diverticulitis) 2. Best test to identify complications
1. Pericolic abscess or (perforation)
2. Free perforation with
generalized peritonitis
3. Fistulas may form
between adjacent
3. Findings suggestive of perforation
structures
1. Pericolic fat infiltration
2. Fascial thickening and muscle
hypertrophy
3. Arrowhead sign
1. Localized bowel wall
thickening
2. Bowel lumen
resembles arrow
3. Symptoms shape at diverticulum
1. Mild anorexia
2. Nausea or Vomiting
3. Chills
4. Diarrhea or cobstipation
5. Abdominal Pain: Acute constant pain 3. AVOID COLONOSCOPY IN ACUTE DISEASE
1. Initial: Hypogastric pain 1. Risk of worsening perforation
2. LATER: LEFT LOWER 4. AVOID BARIUM ENEMA IN ACUTE DISEASE
QUADRANT ABDOMINAL PAIN 1. Risk of extravasation if perforation
(>92%)
6. 7. Management: General Measures
1. Clear Liquid Diet (NPO in severe disease)
2. Low fiber diet in acute phase 9. Management: Inpatient
3. Avoid Narcotics (INCREASES INTRACOLONIC 1. INDICATIONS FOR HOSPITALIZATION
PRESSURE)
1. Age >85 years
1. Except Meperidine (decreases
2. Significant inflammation
intraluminal pressure) 3. Unable to take oral fluids
4. ANTICIPATE IMPROVEMENT WITHIN 48-72 HOURS
2. GENERAL MEASURES
8. Management: Outpatient Mangement 1. Nothing by mouth initially
of mild disease
1. INDICATIONS FOR OUTPATIENT
MANAGEMENT
1. Uncomplicated Diverticulitis 3. ANTIBIOTIC REGIMEN FOR MODERATE
2. Stable clinically DISEASE
3. Tolerating oral fluids 1. Primary agents
1. Unasyn 3 g IV q6 hours
2. Zosyn 3.375 g IV q6 hours
3. Timentin 3.1 g IV q6 hours
2. Alternative agents
2. ANTIBIOTIC REGIMEN 1. Cefoxitin 2 g IV q8 hours
1. Primary protocol (requires 2 agents for 7-
2. Cefotetan 2 g IV q12 hours
10 days)
3. Ciprofloxacin 400 mg IV q12h
1. CIPROFLOXACIN 500 mg PO bid
with Flagyl 500 IV q6h
or Septra DS PO bid and
2. METRONIDAZOLE (Flagyl) 500
mg PO q6 hours
4. ANTIBIOTIC REGIMEN FOR SEVERE DISEASE
(E.G. ICU)
2. Alternative protocol 1. Primary agents
1. AUGMENTIN 500 mg PO 1. Imipenem 500 mg IV q6 hours
or
tid for 7-10 days 2. Merepenem 1 g IV q8 hours
2. Alternative agents
1. Trovafloxacin 300 mg IV day 1,
then 200 mg IV qd or
2. Three agent protocol 1
1. Ampicillin 2 g IV q6
hours and
2. Metronidazole 500 mg
IV q6 hours and
3. Aminoglycoside
(requires monitoring
of levels)
1. Gentamicin
or
2. Tobramycin
or
3. Amikacin
3. Three agent protocol 2
1. Ampicillin 2 g IV q6
hours and
2. Metronidazole 500
mg IV q6 hours
3. Ciprofloxacin 400 mg
IV q12 hours
7. 10.Course
1. Improves on antibiotics within 48 to 72
hours
11.Follow-up
1. COLONOSCOPY 6 WEEKS AFTER
DIVERTICULITIS EPISODE
1. Define extent of Diverticulosis
2. Evaluate for Colon Cancer
3. Barium Enema may be used as alternative
option
2. SURGICAL INDICATIONS
1. Recurrent Diverticulitis (more than
1 episode)
12.Complications
1. Colonic perforation
2. Colonic abscess
3. Generalized peritonitis
4. Colonic fistula
13.Prevention
1. High fiber diet (except in acute phase - see above)
2. Maintain adequate hydration
14.Prognosis
1. After first episode, recurs in 20-30% of cases
2. After second episode, recurs in 50% of cases
15. References
1. Gilbert (2002) Sanford Guide to
Antimicrobials, p. 14
2. Simmang in Feldman (1998)
Gastrointestinal, p. 1793-7
3. Salzman (2005) Am Fam Physician 72:1229
