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Diverticulitis

By age 50, one third of adults have diverticulosis coli; two thirds have diverticulosis by age 80. Ten to 20% of patients with diverticulosis will have complications of diverticulitis or diverticular hemorrhage.

Causes of Diverticulosis. Aging, elevation of colonic intraluminal pressure, and decreased dietary fiber. Diverticula occur where nutrient arteries penetrate the muscularis propria. Eighty-five percent are found in the diverticulitis diverticulitis

Clinical Presentation of Diverticulitis

Diverticulitis is characterized by the abrupt onset of unremitting left-lower quadrant abdominal pain, fever, and an alteration in bowel pattern. Diverticulitis of the transverse colon may simulate ulcer pain; diverticulitis of the cecum and redundant diverticulitis sigmoid may resemble appendicitis.

Right sided diverticulosis is more common among Asians (>75%) than among Europeans. Frank rectal bleeding is usually not seen with diverticulitis.

Physical Exam. Left-lower quadrant tenderness is characteristic. Abdominal examination is often diverticulitis deceptively unremarkable in the elderly and in persons diverticulis

Differential Diagnosis of Diverticulitis
Elderly	Middle Aged and Young
Ischemic colitis Carcinoma Volvulus Colonic diverticulitis Obstruction Penetrating diverticulitis ulcer Nephrolithiasis/urosepsis	Appendicitis Salpingitis Inflammatory bowel disease Penetrating ulcer Urosepsis

Diagnostic Evaluation

Plain X-rays may show ileus, obstruction, mass effect, ischemia, or perforation.

CT scan is the test of choice to evaluate acute diverticulitis. The CT scan can be used for staging the degree of complications and ruling out other diseases.

Contrast Enema. Water soluble contrast is safe and useful in mild-to-moderate cases of diverticulitis when the diagnosis is in doubt.

Endoscopy. Acute diverticulitis is a relative contraindication to endoscopy; perforation should be excluded first. Endoscopy is indicated when the diagnosis is in doubt to exclude the possibility of ischemic bowel, Crohn's disease, or carcinoma.

Ultrasound occasionally is helpful to evaluate acute diverticulitis, although intestinal gas often interferes with the exam.

Complete blood count may show leukocytosis

Treatment

Outpatient Treatment

Clear liquid diet

Oral antibiotics

Ciprofloxacin (Cipro) 500 mg PO bid AND

Metronidazole (Flagyl) 500 mg PO qid.

Inpatient Treatment

Severe cases require hospitalization for gastrointestinal tract rest (NPO), intravenous fluid hydration, correction of electrolyte abnormalities, and antibiotics.

Nasogastric suction is initiated if the patient is vomiting or if there is abdominal distention.

Antibiotic coverage should include enteric gram-negative and anaerobic organisms

Ampicillin 1-2 gm IV q4-6h AND

Gentamicin or tobramycin 100-120 mg IV (1.5-2 mg/kg), then 80 mg IV q8h (5 mg/kg/d) AND

Metronidazole (Flagyl) 500 mg q6-8h (15-30 mg/kg/d).

Monotherapy with a second-generation cephalosporin (eg, cefoxitin, cefotetan) or an extended-spectrum penicillins (eg, piperacillin-tazobactam, ampicillin-sulbactam) also may be used.

The abdomen should be frequently reassessed for the first 48-72 hours. Improvement should occur over 48-72 hours, with decreased fever, leukocytosis, and abdominal pain. Failure to improve or deterioration are indications for reevaluation and consideration of surgery. Analgesics should be avoided because they may mask acute deterioration, and they may obscure the need for urgent operation.

Oral antibiotics should be continued for 1-2 weeks after resolution of the acute attack. Ciprofloxacin, 500 mg PO bid.

After the acute attack has resolved, clear liquids should be initiated, followed by a low residue diet for 1-2 weeks, followed by a high-fiber diet with

Surgical Therapy

An emergency sigmoid colectomy with proximal colostomy is indicated for attacks of diverticulitis associated with sepsis, peritonitis, obstruction, or perforation.