Diverticulitis: Difference between revisions
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==Treatment==
==Treatment==
*Antibiotics are aimed at treating [[Gram Negative]] organisms and [[Anerobes]] (Enterobacteriaceae, [[Pseudomonas aeruginosa]], [[Bacteroides fragilis|Bacteriodes sp.]], and Enterococci)<ref>Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35</ref>
*Antibiotics are aimed at treating [[Gram Negative]] organisms and [[Anerobes]] (Enterobacteriaceae, [[Pseudomonas aeruginosa]], [[Bacteroides fragilis|Bacteriodes sp.]], and Enterococci)<ref>Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35</ref>
#Uncomplicated
===Uncomplicated===
##Liquid diet
*Liquid diet and bowel rest are most important
##Abx
;Antibiotics:
###Metronidazole 500mg PO TID AND ciprofloxacin 500mg PO BID x10-14d OR
#Metronidazole 500mg PO TID AND ciprofloxacin 500mg PO BID x10-14d OR
###Amoxicillin-clavulanate 875/125 PO BID x10-14d
#Amoxicillin-clavulanate 875/125 PO BID x10-14d
#Complicated (phlegmon, abscess, stricture, obstruction, fistula, perforation)
 
##Liquid diet
Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient's receive sufficient bowel rest<ref>Chabok A. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688</ref>
##Abx
 
###Piperacillin-tazobactam 3.35gm IV q6hr or 4.5 gm q8hr OR
===Complicated===
###[[Ceftriaxone]] 1 gm IV QD AND metronidazole 500mg IV q8-12hr OR
*Defined as having a  phlegmon, abscess, stricture, obstruction, fistula, or perforation
###Imipenem 500 mg q6hr
*Bowel rest in coordination with antibiotics
*Surgical consult for drainage of abscess or further surgical intervention
;Antibiotics:
#Piperacillin-tazobactam 3.35gm IV q6hr or 4.5 gm q8hr OR
#[[Ceftriaxone]] 1 gm IV QD AND metronidazole 500mg IV q8-12hr OR
#Imipenem 500 mg q6hr


==Disposition==
==Disposition==

Revision as of 02:44, 30 June 2014

Background

  • Prevalence of diverticulosis 30% by age 60, >70% by age 85
  • 70% of pts w/ diverticulosis remain asymptomatic
  • Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Asia)
  • Pathogenesis
    • Erosion of diverticular wall by inspissated fecal material leads to microperforation
      • Most common pathogens are anaerobes, as well as gram-negative rods
  • Diverticular bleeding (painless LGIB) is NOT associated w/ diverticulitis

Clinical Features

  • LLQ abdominal pain
    • Asian pt may c/o RLQ or suprapubic pain
  • Fever
  • Leukocytosis
  • Change in bowel habits: diarrhea (30%) or constipation (50%)
  • N/V
  • Anorexia

DDX

  1. Appendicitis
  2. Colitis—ischemic or infectious
  3. Inflammatory bowel disease (Crohn disease, ulcerative colitis)
  4. Colon cancer
  5. Irritable bowel syndrome
  6. Pseudomembranous colitis
  7. Epiploic appendagitis
  8. Gallbladder disease
  9. Incarcerated hernia
  10. Mesenteric infarction
  11. Complicated ulcer disease
  12. Peritonitis
  13. Obstruction
  14. Ovarian torsion
  15. Ectopic pregnancy
  16. Ovarian cyst or mass
  17. Pelvic inflammatory disease
  18. Cystitis
  19. Kidney stone
  20. Renal pathology
  21. Pancreatic disease

Diagnosis

  • Stable pt w/ h/o confirmed diverticulitis does not require further diagnostic evaluation
    • 1st time episode or current episode different from previous requires diagnostic imaging


Work-Up

  1. Labs
    1. CBC
    2. Chemistry
    3. LFTs
    4. Lipase
    5. UA
  2. Imaging
    1. CT w/ IV and PO contrast
      1. Sn 97%, Sp 100%

Treatment

Uncomplicated

  • Liquid diet and bowel rest are most important
Antibiotics
  1. Metronidazole 500mg PO TID AND ciprofloxacin 500mg PO BID x10-14d OR
  2. Amoxicillin-clavulanate 875/125 PO BID x10-14d

Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient's receive sufficient bowel rest[2]

Complicated

  • Defined as having a phlegmon, abscess, stricture, obstruction, fistula, or perforation
  • Bowel rest in coordination with antibiotics
  • Surgical consult for drainage of abscess or further surgical intervention
Antibiotics
  1. Piperacillin-tazobactam 3.35gm IV q6hr or 4.5 gm q8hr OR
  2. Ceftriaxone 1 gm IV QD AND metronidazole 500mg IV q8-12hr OR
  3. Imipenem 500 mg q6hr

Disposition

  1. Admit
    1. All complicated diverticulitis
    2. Intractable N/V, comborbid disease, high WBC, high fever, elderly, immunocompromised
    3. Failed outpt therapy (worsening symptoms or CT findings w/in 6wk of initial episode)
  2. Discharge
    1. Well-appearing, immunocompetent pts w/ uncomplicated disease
    2. Refer all newly-diagnosed pts for f/u colonoscopy in 6 wk (CT cannot r/o carcinoma)
    3. Surgical referral should be made for all pts w/ 2nd episode of diverticulitis

Source

Tintinalli

  1. ↑ Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35
  2. ↑ Chabok A. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688
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