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]

Definition

Causes

Life Threatening 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 or preirectal fullness
Fever
Leukocytosis
Nausea
Vomits
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:

❑ Ectoscopy:

❑ Obesity

❑ Measure the heart rate
❑ Measure the temperature
❑ Abdomen:

❑ Rigidty
❑ Tendernes
 
 
 
 
 
Order labs and tests:[3]

❑ CT
❑ Blood Count:

❑ Leukocytes

❑ Abdominal X-rays with soluble contrast

Urianalysis

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
❑ Inmunocompetent patient
❑Tolerated oral intake
❑Single episode
❑Mild to moderate pain
 
Hospitalized
❑Unable to tolerate oral intake
❑Severe pain
❑Inmunocompromised patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical Treatment[3]

Oral regimens
Metronidazole (500mg / 6 - 8 hrs) + Quinolone (e.g. Ciprofloxacin 500 - 700mg / 12hrs)
Metronidazole (500mg / 6 - 8 hrs) + Trimethoprim (160mg / 12 hrs) - Sulfamethoxazole (800mg / 12hrs)
Amoxicillin- clavulanate (875mg / 12hrs)

 
Medical Treatment[3]

Intravenous regimen
Metronidazole (500mg / 6 - 8 hrs) + Quinolone (e.g. Ciprofloxacin 400mg / 12hrs)
Metronidazole (500mg / 6 - 8 hrs) + Third-generation cephalosporin (e.g. Ceftriaxone 1 - 2g / 12hrs)

Beta-lactam with Beta-lactamase inhibitor (e.g. Ampicillin sulbactam 3g / 6hrs)
 
 
 
 
 
 
 
 
 
Stage the severity by using:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If after 2 to 3 days patient:

❑ Doesn't respond to treatment
❑ Repeat episodes

❑ Complicates
 
 
 
Mild
 
 
 
Moderate
 
 
Severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical Consultation
 
 
 
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
 
 
 
❑ 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

  • Colonoscopy and sigmoidoscopy could be performed 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 surgery laparoscopically, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
  • Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
  • Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
  • 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.
  • Elective single stage colectomy is viable 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.
  • 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.

Don'ts

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.


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