Updated: 12/15/2021

Diverticulitis

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  • Snapshot
    • A 63-year-old female is brought to the emergency room for severe abdominal pain for the past 1 day. She reports that the pain is 9/10, dull, with intermittent exacerbations concentrated at the left lower quadrant (LLQ). She endorses low-grade fever, nausea, and vomiting for the past couple of hours. Her past medical history includes hypertension, constipation, and diverticulosis. A physical examination demonstrates abdominal tenderness and some diffuse voluntary guarding.
  • Introduction
    • Clinical definition
      • gastrointestinal disease characterized by the inflammation of diverticula
        • results from a microscopic or macroscopic perforation of a diverticulum due to diverticular inflammation and focal necrosis
      • patients can present with repeated attacks
      • complicated diverticulitis is defined as diverticulitis with 1 of the following associated complications
        • bowel obstruction
        • abscess
        • fistula
        • perforation
  • Epidemiology
    • Demographics
      • most commonly occurs at the sigmoid colon in North America, reflecting the distribution of diverticulosis
      • right-sided (cecal) diverticulitis is more common in Asian populations
      • approximately 4% of patients with diverticulosis develop acute diverticulitis
    • Risk factors
      • obesity
      • lack of exercise
      • smoking
      • positive family history
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
  • ETIOLOGY
    • Pathogenesis
      • primary process is thought to be due to erosion of the diverticular wall by increased intraluminal pressure or inspissated food particles
        • erosions of the wall then lead to inflammation and focal necrosis that may lead to micro- or macroscopic perforation
      • the inflammation is frequently mild and often walled off by pericolic fat and mesentery
        • this may lead to the formation of a localized abscess or a fistula (if adjacent organs are involved)
        • poor containment of the inflamed diverticulum or abscess can result in free perforation and peritonitis
  • Presentation
    • Symptoms
      • abdominal pain
        • most commonly at the LLQ
      • nausea
      • vomiting
      • constipation
      • diarrhea
    • Physical exam
      • fever
      • hypotension
      • tender mass
      • peritoneal signs (e.g., guarding, rigidity, and rebound tenderness)
  • imaging
    • Computed tomography (CT) with oral and IV contrast
      • positive findings include localized wall thickening (> 4mm), pericolic fat stranding, and presence of colonic diverticula
      • also allows for visualizations of complications such as abscess, obstruction, or perforation
    • Abdominal ultrasound
      • indicated in patients who cannot receive radiation
      • positive findings include bowel wall thickening, hypoechoic peridiverticular inflammatory reaction, and the presence of diverticula
    • Abdominal and chest radiographs
      • may be useful in detecting pneumoperitoneum and obstruction
      • positive findings include air-fluid levels with bowel dilation or free air
    • Colonoscopy
      • not to be performed during acute diverticulitis for risk of perforation
      • recommended 4-6 weeks after resolution for evaluation and rule out of malignancy
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is based on clinical presentation and is confirmed via imaging studies
      • studies
        • complete blood count
          • may see leukocytosis
        • urinalysis
          • may see sterile pyuria or colonic flora (if colovesical fistula)
        • pregnancy test indicated in all women of childbearing age
  • Differential
    • Inflammatory bowel syndrome (IBD)
      • differentiating factors
        • will often present with more chronic clinical symptoms and will have positive biopsy findings
    • Colorectal cancer
      • differentiating factors
        • will be visualized on colonoscopy
    • Acute appendicitis
      • differentiating factors
        • will appear differently on abdominal CT imaging
  • Treatment
    • Management depends on disease severity, certain characteristics, and the presence of complications
      • the majority of patients with acute diverticulitis can be treated with medical management
    • Outpatient treatment
      • indicated for patients with uncomplicated diverticulitis and no signs of high fever, significant leukocytosis, peritoneal signs, sepsis, immunosuppression, advanced age, intolerance of oral intake, or significant comorbidities
      • oral antibiotics for 7-10 days with following 2-3 days after first visit
    • Inpatient medical management
      • IV antibiotics with transition to oral antibiotics with improvement
        • Gram-negative and anaerobic coverage required
      • IV fluids
      • Parenteral pain medications
      • NPO if unable to tolerate oral intake
    • Surgery
      • indicated for patients with perforated diverticulitis, hemodynamic instability, or peritonitis
      • can be offered electively to patients with recurrent or chronic symptoms, patients who are immunosuppressed or with a prior episode of complicated diverticulitis
  • Complications
    • Abscess
      • should be suspected in patients with uncomplicated diverticulitis showing no improvement despite 3 days of antibiotic treatment
      • if < 3cm, then treat with IV antibiotics
      • if > 3cm, consider CT-guided percutaneous drainge
    • Bowel obstruction
    • Diverticular fistula
    • Perforation
    • Peritonitis
    • Shock

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(M2.GI.16.73) A 71-year-old female presents to her primary care physician with a four-day history of left lower quadrant abdominal pain. The patient also complains of diarrhea and mild nausea. She continues to tolerate a diet, though reduced in quantity. On exam, her vitals are T 101F HR 86, BP 130/92, RR 15, and SaO2 100%. Abdominal exam is notable for left lower quadrant tenderness to palpation without rebound or guarding. Urine dipstick is normal and complete blood count shows a minor leukocytosis with a left shift. A screening colonoscopy from a year ago is shown in Figure A. What is the next best step in management?

QID: 106561
FIGURES:

Immediate colonoscopy

20%

(1/5)

Trimethoprim-sulfamethoxazole and a liquid diet

40%

(2/5)

Abdominal CT with IV contrast

40%

(2/5)

CT angioplasty of mesenteric vessels

0%

(0/5)

Laparotomy and surgical management

0%

(0/5)

M 7 C

Select Answer to see Preferred Response

(M3.GI.16.47) A 65-year-old man with a history of constipation is admitted to your floor with left lower quadrant pain. The patient states that he has been previously admitted with similar pain. He denies any medical history, but states that he does not like to eat vegetables. His wife states that he has had increasing pain over the last few days and that this time, the pain is more intense and that the patient has had higher fevers of up to 102°F (38.9°C). On exam, the patient's vitals are HR 102, T 101.9°F (38.8°C), BP 140/60, and RR 14. The patient has tenderness to palpation along with rebounding and guarding. Figure A shows a CT scan of the patient's abdomen and pelvis. What is the definitive treatment for this patient?

QID: 103338
FIGURES:

Antibiotics and surveillance

60%

(3/5)

Discharge home

0%

(0/5)

Emergent operative treatment

20%

(1/5)

Percutaneous drainage

20%

(1/5)

Fluids

0%

(0/5)

M 11 C

Select Answer to see Preferred Response

(M2.GI.16.4672) A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease?

QID: 107190

Abdominal x-ray

0%

(0/5)

Lipase

0%

(0/5)

Abdominal CT

100%

(5/5)

Left lower quadrant ultrasound

0%

(0/5)

Emergent colonoscopy

0%

(0/5)

M 6 C

Select Answer to see Preferred Response

(M3.GI.13.51) A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 13,500/mm^3
Platelet count: 157,000/mm^3

Which of the following is the most appropriate next step in management?

QID: 102680

Ceftriaxone and metronidazole

17%

(1/6)

Ciprofloxacin and metronidazole

0%

(0/6)

Colonoscopy

17%

(1/6)

CT abdomen

67%

(4/6)

MRI abdomen

0%

(0/6)

M 10 E

Select Answer to see Preferred Response

(M2.OMB.2) A 67-year-old woman presents to the emergency department with diffuse abdominal pain. She states that it started yesterday and has been gradually worsening. She endorses subjective fevers and diarrhea that she believes to be worsening. She has a history of obesity and diabetes. Her temperature is 102°F (38.9°C), blood pressure is 110/80 mmHg, pulse is 122/min, and respirations are 16/min. Physical exam reveals a fast, regular heart rate and left lower quadrant abdominal tenderness. A CT scan demonstrates fat stranding and edema surrounding the colon with a small amount of intraperitoneal free air. Which of the following is the most appropriate antibiotic regimen for this patient?

QID: 216356

Ceftriaxone and metronidazole

0%

(0/0)

Daptomycin and clindamycin

0%

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Linezolid and clindamycin

0%

(0/0)

Vancomycin and cefepime

0%

(0/0)

Vancomycin and metronidazole

0%

(0/0)

M 11

Select Answer to see Preferred Response

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