Diverticulitis: Difference between revisions
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*Antibiotics are aimed at treating [[Gram Negative]] organisms and [[Anaerobes]] (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 [[Anaerobes]] (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===
''Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient receives sufficient bowel rest in coordination with medicine observation and close follow up. Antibiotics do not speed recovery or rate of recurrence. At the very least, shorter durations (5 days) of antibiotics should be prefered compared to historic 10-14day courses''<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><ref>The STAND trial: Jaung R, Nisbet S, Gosselink MP, Di Re A, Keane C, Lin A, Milne T, Su’a B, Rajaratnam S, Ctercteko G, Hsee L, Rowbotham D, Hill A, Bissett I. Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clin Gastroenterol Hepatol. 2020 Mar 30:S1542-3565(20)30426-2. doi: 10.1016/j.cgh.2020.03.049. PMID: 32240832</ref>
''Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient receives sufficient bowel rest in coordination with medicine observation and close follow up. Antibiotics do not shorten time to recovery or decrease rate of recurrence. At the very least, shorter durations (5 days) of antibiotics should be prefered compared to historic 10-14day courses''<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><ref>The STAND trial: Jaung R, Nisbet S, Gosselink MP, Di Re A, Keane C, Lin A, Milne T, Su’a B, Rajaratnam S, Ctercteko G, Hsee L, Rowbotham D, Hill A, Bissett I. Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clin Gastroenterol Hepatol. 2020 Mar 30:S1542-3565(20)30426-2. doi: 10.1016/j.cgh.2020.03.049. PMID: 32240832</ref>
*Modified [[Hinchey]] Class 0
*Modified [[Hinchey]] Class 0
*Liquid diet and bowel rest (low fiber foods) are most important
*Liquid diet and bowel rest (low fiber foods) are most important

Revision as of 12:32, 30 September 2022

Background

Section of the large bowel (sigmoid colon) showing multiple pouches (diverticula). The diverticula appear on either side of the longitudinal muscle bundle (taenium) which runs horizontally across the specimen in an arc.
  • Prevalence of diverticulosis 30% by age 60, >70% by age 85
  • 70% of patients with diverticulosis remain asymptomatic
  • 13% of diverticulitis is found in patients <40 yrs of age[1]
  • Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Japan)[2]
  • 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 lower gastrointestinal bleeding) is NOT associated with diverticulitis

Clinical Features

Differential Diagnosis

LLQ Pain

Evaluation

Diverticulitis in the left lower quadrant as seen on axial view by a CT scan.
CT demonstrating diverticulitis: edema and thickening of the sigmoid colon wall (arrow) with diverticulum and adjacent fat stranding.

Work-Up

  • Labs
  • Imaging
    • CT with IV and PO contrast (Sn 97%, Sp 100%)
      • Pericolic stranding
      • Bowel wall thickening
      • Wall enhancement (inner and outer high attenuation layers)
      • Perforation - extravasation of air/fluid
      • Abscess in 30% with fluid and/or gas
      • Bladder fistula
    • Ultrasound (Sn >90%)[3]
      • Highly operator-dependent
      • Can identify diverticula, bowel wall thickening, inflammation, or abscess formation
    • MRI (Sn 98%, Sp 70-78%)[4]
      • Difficult to obtain quickly in ED

Evaluation

  • Stable patient with history of confirmed diverticulitis does not require further diagnostic evaluation
    • 1st time episode or current episode different from previous requires diagnostic imaging

Modified Hinchey Classification[5]

  • 0 Mild clinical diverticulitis
  • Ia Confined pericolic inflammation or phlegmon
  • Ib Pericolic or mesocolic abscess
  • II Pelvic, distant intraabdominal, or retroperitoneal abscess
  • III Generalized purulent peritonitis
  • IV Generalized fecal peritonitis

Management

Uncomplicated

Current research suggests that antibiotics may not be necessary in uncomplicated diverticulitis if patient receives sufficient bowel rest in coordination with medicine observation and close follow up. Antibiotics do not shorten time to recovery or decrease rate of recurrence. At the very least, shorter durations (5 days) of antibiotics should be prefered compared to historic 10-14day courses[8][9]

  • Modified Hinchey Class 0
  • Liquid diet and bowel rest (low fiber foods) are most important

Antibiotic

  • First, consider whether antibiotics are needed:
  • In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[10][11]
  • Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[10]

If antibiotics are prescribed (4-7 day course preferred):[10]

Preferred:

  • Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[12][13]
    • Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[13]
    • Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[14]

Alternatives (penicillin allergy or intolerance):

Complicated

  • Defined as having a phlegmon, abscess, stricture, obstruction, fistula, or perforation (i.e. Hinchey Stages I-IV; see Evaluation section)
  • Bowel rest in coordination with antibiotics
  • Surgical consult for drainage of abscess or further surgical intervention

Disposition

Admit

  • All complicated diverticulitis
  • Intractable nausea/vomiting
  • Comborbid disease
  • High WBC, high fever, elderly, immunocompromised
  • Failed outpatient therapy (worsening symptoms or CT findings within 6 weeks of initial episode)
  • Large abscess > 3-4cm requiring percutaneous drainage with CT or US[16]

Discharge

  • Patients may be treated as outpatients if:[17]
    • Can tolerate PO
    • No significant comorbidities
    • Able to obtain outpatient antibiotics
    • Have adequate pain control
    • Have uncomplicated disease
  • Refer all newly-diagnosed patients for follow up colonoscopy in 6 weeks (CT cannot rule out carcinoma)
  • Surgical referral should be made for all patients with 3rd episode of diverticulitis

See Also

References

  1. ↑ Schneider EB, et al. Emergency department presentation, admission, and surgical intervention for colonic diverticulitis in the United States. American Journal of Surgery. April 29, 2015.
  2. ↑ Peterson MA, Wu AW. Disorders of the large intestine. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:(Ch) 85:1150–1165.
  3. ↑ Dirks K, Calabrese E, Dietrich CF, et al. EFSUMB Position Paper: Recommendations for Gastrointestinal Ultrasound (GIUS) in Acute Appendicitis and Diverticulitis. EFSUMB-Positionspapier: Empfehlungen für den gastrointestinalen Ultraschall (GIUS) bei akuter Appendizitis und Divertikulitis. Ultraschall Med. 2019;40(2):163-175. doi:10.1055/a-0824-6952
  4. ↑ Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP. Toward an evidence-based step-up approach in diagnosing diverticulitis. Scand J Gastroenterol. 2014;49(7):775-784. doi:10.3109/00365521.2014.908475
  5. ↑ Wasvary H, Turfah F, Kadro O, et al. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65:632–635.
  6. ↑ Stollman N, Smalley W, and Hirano I. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015; 149(7):1944-1949.
  7. ↑ Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35
  8. ↑ 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
  9. ↑ The STAND trial: Jaung R, Nisbet S, Gosselink MP, Di Re A, Keane C, Lin A, Milne T, Su’a B, Rajaratnam S, Ctercteko G, Hsee L, Rowbotham D, Hill A, Bissett I. Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clin Gastroenterol Hepatol. 2020 Mar 30:S1542-3565(20)30426-2. doi: 10.1016/j.cgh.2020.03.049. PMID: 32240832
  10. ↑ 10.0 10.1 10.2 Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059
  11. ↑ Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
  12. ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
  13. ↑ 13.0 13.1 Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315
  14. ↑ 14.0 14.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
  15. ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
  16. ↑ Siewert B et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol. 2006 Mar;186(3):680-6.
  17. ↑ Friend K, Mills AM. Annals of EM. 2011.
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