5MinuteConsult | Diverticulitis, Emergency Medicine

6/25/15, 8:33 AM

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
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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):
Phlegmoninflamed 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
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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 airfluid 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

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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
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Amoxicillin/clavulanate
Duration of therapy is 1014 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 23 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
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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,
57 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), 1014 days
Amoxicillinclavulanate 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

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Significant leukocytosis
Immunocompromised or steroid-dependent patients
Recurrent episodes
Comorbidities: Renal insuciency, 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 dierentiates 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
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Lorimer JW, Doumit G. Comorbidity is a major determinant of severity in acute diverticulitis. Am J Surg. 2007;193:681685.
Nelson RS, Ewing BM, Wengert TJ, et al. Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J
Surg. 2008;196(6):969972.
Raerty 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;49:939944.
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;94:31103121.
Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am. 2009;38(3):513525.
Yoo PS, Garg R, Salamone LF, et al. Medical comorbidities predict the need for colectomy for complicated and recurrent
diverticulitis. Am J Surg. 2008;196:710714.

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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