Diverticulitis

Ekaterine labadze MD
 Definition

 Diverticulitis is defined as an inflammation of one or more diverticula, which

are small pouches created by herniation of the mucosa into the wall of the
colon.
 Diverticulitis is generally considered a disease of the elderly, but as many as
20% of patients with diverticulitis are younger than 50 years
 Diverticular disease includes a spectrum of conditions ranging from
asymptomatic diverticular disease, to symptomatic uncomplicated
diverticular disease, and complicated diverticular disease that includes acute
and chronic diverticulitis.
 Signs and symptoms

The clinical presentation of diverticulitis depends on the

location of the affected diverticulum, the severity of the
inflammatory process, and the presence of complications.
Presenting complaints include the following:
 Left lower quadrant pain (70% of patients)
 Change in bowel habits
 Nausea and vomiting
 Constipation
 Diarrhea
 Flatulence
 Bloating
 Physical Examination

 Left lower quadrant tenderness is the most common physical finding, as most
diverticula occur in the sigmoid colon
 Elderly patients and some patients taking corticosteroids may have
unremarkable findings on physical examination even in the presence of severe
diverticulitis.
 In complicated diverticulitis with abscess formation, a tender palpable mass
may be felt on physical examination.
 Laboratory Studies

The diagnosis of acute diverticulitis can usually be made on the

basis of history and physical examination. Laboratory tests may be
of help when the diagnosis is in question.
 A hemogram may reveal leukocytosis and a left shift, indicating infection
 Liver tests and lipase may help to exclude other causes of abdominal
pain.
 Chemistries may be helpful in the patient who is vomiting or has diarrhea
to assess electrolyte abnormalities.
 Renal function is assessed prior to the administration of most intravenous
contrast material.
 A pregnancy test must be performed in any female of childbearing age
who presents with abdominal pain to rule out ectopic pregnancy.
 Imaging Studies

 The diagnosis of diverticulitis can be made on clinical grounds, but a

computed tomography (CT) scan of the abdomen is considered the best
imaging method to confirm the diagnosis.

 CT scans can help assess disease severity, the presence of complications, and
clinical staging.

 In the acute setting, CT scans are safer than contrast studies.

 Procedures

 Endoscopy is not recommended in the acute setting given the risk of

worsening diverticulitis and bowel perforation.

 After the diverticulitis has subsided, colonoscopy can be used to evaluate

the extent of diverticulosis or to rule out a malignancy masquerading as a
benign post inflammatory stricture.
 Classification

Clinical staging by Hinchey's classification is geared toward choosing the proper

surgical procedure when diverticulitis is complicated, as follows:

 Stage I disease - Phlegmon or localized pericolic or mesenteric

abscess
 Stage II disease - Walled-off pelvic, intra-abdominal, or
retroperitoneal abscess
 Stage III disease - Perforated diverticulitis causing generalized
purulent peritonitis
 Stage IV disease - Rupture of diverticula into the peritoneal
cavity with fecal contamination causing generalized fecal perit
 Treatment & Management

About 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease
that requires surgery.
The classic surgical indications include :
 Free-air perforation with fecal peritonitis
 Uncontrolled sepsis
 Abdominal or pelvic abscess
 Fistula formation
 Inability to rule out carcinoma
 Intestinal obstruction
 Failing medical therapy
 Immunocompromised status
 Extremes of age
 Medical Care

The American Gastroenterological Association (AGA) suggests selective, rather than

routine, use of antibiotics in patients with acute uncomplicated diverticulitis.
According to the World Gastroenterology Organisation (WGO) 2007 practice guidelines
for diverticular disease, such a regimen should result in improvement within 48-72
hours.
Note the following:
 One typical oral antibiotic regimen is a combination of ciprofloxacin (or
trimethoprim-sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate
monotherapy for outpatient treatment of uncomplicated diverticulitis.
Amoxicillin/clavulanic acid monotherapy is acceptable as well.
 Patients should be instructed to be on a clear liquid diet only and can advance the
diet slowly as tolerated after clinical improvement, which usually occurs within 2-
3 days.
 Questions

 What is diverticulitis?
 What are the symptoms of diverticulitis?
 Which lab tests may be useful in the diagnosis of diverticulitis?
 Which imaging method is used to confirm the diagnosis of diverticulitis?
 What is the role of the Hinchey classification for diverticulitis?
 What are the surgical indications for diverticulitis?
 Which medications are used to treat diverticulitis?