Diverticulitis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Overview

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease, causing fever, leukocytosis and lower abdominal pain. It could be simple or complicated, which includes gross or microscopical perforation, obstruction, the formation of abscesses or fistulization.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Diverticulitis is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to diverticulitis according to the American Society of Colon and Rectal Surgeons[1] and the American Journal of Gastroenterology[2]

Characterize the symptoms:[3]

Abdominal pain

❑ Lower left quadrant

❑ Abdominal fullness
Fever
Nausea
Vomiting
Pneumaturia
Fecaluria[1]
Pneumaturia

Pyuria
 
 
 
 
 
Obtain a detailed history:[4]

❑ Age
❑ Previous history of diverticular disease
❑ Previous episodes of diverticulitis
❑ Chronic Abdominal pain
❑ Previous history of abdominal surgery
❑ Dietary regime
❑ History of:

Irritable bowel syndrome
❑ Inflammatory bowel disease
Colitis[5]
Immunodeficiency[6]
 
 
 
 
 
Examine the patient:

Vital signs
❑ Obesity
❑ Abdomen

❑ Tenderness (localized or diffused)
❑ Guarding
❑ Rigidity
 
 
 
 
 
Consider alternative diagnoses:

Urinary tract infection
Kidney stones
Bowel obstruction
Irritable bowel syndrome
Appendicitis
Inflammatory bowel disease
Mesenteric ischemia
Malignancy

❑ Gynecological diseases
 
 
 
 
 
Order labs:[3]

❑ Complete blood count
Urianalysis


Order imaging studies:
CT scan of the abdomen and pelvis

❑ Presence of diverticula
❑ Inflammation of the pericolic fat
❑ Bowel-wall thickness > 4 mm
❑ Peridiverticular abscess

❑ Abdominal X-rays with soluble contrast

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to diverticulitis according to the American Journal of Gastroenterology[2] and the American Society of Colon and Rectal Surgeons [1]

 
 
 
 
 
 
 
 
 
Initial Management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncomplicated
 
 
 
 
 
 
 
 
 
 
 
Complicated[7]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Outpatient
❑ Inmunocompetence
❑ Tolerated oral intake
❑ Single episode
❑ Mild to moderate pain
 
Hospitalized
❑ Immunocompromise
❑ Unable to tolerate oral intake
❑ Severe pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical treatment[3]

❑ Administer oral broad spectrum antibiotics for 7 days

Metronidazole (500 mg/ 6-8 hrs) + quinolone (e.g. ciprofloxacin 500 - 750 mg/ 12 hrs)
Metronidazole (500 mg/ 6-8 hrs) + trimethoprim (160 mg / 12 hrs)/sulfamethoxazole (800 mg/ 12 hrs)
Amoxicillin - clavulanate (875 mg/ 12 hrs)
 
Medical treatment[3]

❑ Administer intravenous broad spectrum antibiotics

Metronidazole (500mg/ 6-8 hrs) + quinolone (e.g. ciprofloxacin 400mg/ 12 hrs)
Metronidazole (500mg/ 6-8 hrs) + third-generation cephalosporin (e.g. ceftriaxone 1-2g / 24 hrs)
Beta-lactam with beta-lactamase inhibitor (e.g. ampicillin sulbactam 3g / 6 hrs)

❑ Keep nothing by mouth
❑ Insert nasogastric tube in case of evidence of obstruction or ileus

 
 
 
 
 
 
 
 
 
Stage the severity by using:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ No response to treatment in 2-3 days
❑ Worsening of signs and symptoms
❑ Recurrence of attacks
❑ Uncertain diagnosis

❑ Occurrence of complications (fistula, perforation or obstruction)
 
 
 
 
 
Mild
 
 
 
Moderate
 
 
Severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Repeat CT scan
❑ Obtain a surgical consult
 
 
 
 
 
Hinchey Stage I
❑Small precolic abscess (<4cm in diameter)
❑Without peritonitis
 
 
 
Hinchey Stage II
❑Peridiverticular abscess (>4cm in diameter)
 
 
Hinchey Stage III and IV

❑Generalized peritonitis
❑Uncontrolled sepsis
❑Uncontained visceral perforation

❑Large inaccessible abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat conservatively

❑ Bowel rest
❑Broad - spectrum antibiotics intravenously
❑Pain control
 
 
 
Percutaneous Drainage ❑ Bowel rest
❑Broad - spectrum antibiotics intravenously
❑CT-guided percutaneous drainage
❑Pain control
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient doesn't respond to treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Traditional two or three stage surgery
 
One stage surgical approach if possible (generally after percutaneous drainage)
 
Laparoscopy surgery if specialist available
 
 
 

European Association for Endoscopic Surgery clinical Classification[8]

Grades Clinical Description
Grade I
  • symptomatic
  • uncomplicated disease
  • Fever
  • Abdominal pain
Grade II
  • recurrent
  • symptomatic disease
Recurrence of above
Grade III
  • complicated disease
  • Abscess
  • Hemorrhage
  • Fistula
  • Phelgmom
  • Perforation
  • Obstruction
  • Purulent and fecal peritonitis

Buckley Classification[2]

CT Findings
Mild
Bowel wall thickening
Moderate
  • Bowel wall thickening > 3mm
  • Phelgmon or small abscess
Severe
  • Bowel wall thickening > 5mm
  • Perforation with subdiaphragmatic free air
  • Abscess > 5mm

Hinchey's Classification [3]

Stages CT Findings
Stage 1
  • Small confined precolic or mesenteric abscess
Stage 2
  • Large abscess confined to the pelvis
Stage 3
  • Perforated diverticulitis
  • Peridiverticular abscess has ruptured
Stage 4
  • Free rupture of diverticula into the peritoneal cavity

Do´s

  • Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
  • Do insert a nasogastric tube if evidence of obstruction or ileus.
  • Do perform a percutaneous drainage if planning for a successful one stage procedure.
  • Do perform Laparoscopic surgery, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.[9]
  • Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.[10]
  • Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
  • Do use ultrasound and MRI are useful alternative in the initial evaluation.
  • Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.[11]
  • Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
  • Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.[12]
  • Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.[13] [14]
  • Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.[15]
  • Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

Don'ts

  • Do not perform colonoscopy and sigmoidoscopy, when suspecting acute diverticulitis, because of the risk of perforation.
  • Do not reverse a colostomy in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.[16]
  • Do not recommend elective resection solely on the patients age (<50 years old).
  • Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
  • Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.[14]

References

  1. 1.0 1.1 1.2 Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD; et al. (2014). "Practice parameters for the treatment of sigmoid diverticulitis". Dis Colon Rectum. 57 (3): 284–94. doi:10.1097/DCR.0000000000000075. PMID 24509449.
  2. 2.0 2.1 2.2 Sheth AA, Longo W, Floch MH (2008). "Diverticular disease and diverticulitis". Am J Gastroenterol. 103 (6): 1550–6. doi:10.1111/j.1572-0241.2008.01879.x. PMID 18479497.
  3. 3.0 3.1 3.2 3.3 3.4 Jacobs DO (2007). "Clinical practice. Diverticulitis". N Engl J Med. 357 (20): 2057–66. doi:10.1056/NEJMcp073228. PMID 18003962.
  4. Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H (2011). "How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system". Ann Surg. 253 (5): 940–6. doi:10.1097/SLA.0b013e3182113614. PMID 21346548.
  5. Lamps LW, Knapple WL (2007). "Diverticular disease-associated segmental colitis". Clin Gastroenterol Hepatol. 5 (1): 27–31. doi:10.1016/j.cgh.2006.10.024. PMID 17234553.
  6. Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL (1991). "Acute diverticulitis. A complicated problem in the immunocompromised patient". Arch Surg. 126 (7): 855–8, discussion 858-9. PMID 1854245.
  7. Floch MH (2006). "A hypothesis: is diverticulitis a type of inflammatory bowel disease?". J Clin Gastroenterol. 40 Suppl 3: S121–5. doi:10.1097/01.mcg.0000225502.29498.ba. PMID 16885694.
  8. Köhler L, Sauerland S, Neugebauer E (1999). "Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery". Surg Endosc. 13 (4): 430–6. PMID 10094765.
  9. Wexner SD, Moscovitz ID (2000). "Laparoscopic colectomy in diverticular and Crohn's disease". Surg Clin North Am. 80 (4): 1299–319. PMID 10987037.
  10. Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J (1997). "Surgical management of complicated colonic diverticulitis". Br J Surg. 84 (3): 380–3. PMID 9117315.
  11. Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ; et al. (2006). "Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage". Dis Colon Rectum. 49 (2): 183–9. doi:10.1007/s10350-005-0274-7. PMID 16322960.
  12. Pokala N, Delaney CP, Kiran RP, Bast J, Angermeier K, Fazio VW (2007). "A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery". Int J Colorectal Dis. 22 (6): 683–7. doi:10.1007/s00384-006-0219-1. PMID 17031654.
  13. Fry DE (2011) Colon preparation and surgical site infection. Am J Surg 202 (2):225-32. DOI:10.1016/j.amjsurg.2010.08.038 PMID: 21429471
  14. 14.0 14.1 Hayashi MS, Wilson SE (2009). "Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery?". Surg Infect (Larchmt). 10 (3): 285–8. doi:10.1089/sur.2008.9958. PMID 19485781.
  15. Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA (2010). "Indications for elective sigmoid resection in diverticular disease". Ann Surg. 251 (4): 670–4. doi:10.1097/SLA.0b013e3181d3447d. PMID 20224374.
  16. Ferzoco LB, Raptopoulos V, Silen W (1998). "Acute diverticulitis". N Engl J Med. 338 (21): 1521–6. doi:10.1056/NEJM199805213382107. PMID 9593792.


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