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Updated: Dec 15 2021


  • 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)
    • 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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