Diverticulitis: Difference between revisions
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*Prevalence of diverticulosis 30% by age 60, >70% by age 85 | *Prevalence of diverticulosis 30% by age 60, >70% by age 85 | ||
*70% of pts w/ diverticulosis remain asymptomatic | *70% of pts w/ diverticulosis remain asymptomatic | ||
*13% of diverticulitis is found in patients <40 yrs of age<ref>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.</ref> | *13% of diverticulitis is found in patients <40 yrs of age<ref>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.</ref> | ||
*Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Asia) | *Diverticular disease is almost exclusively left-sided colon (USA) or right-sided (Asia) | ||
*Pathogenesis | *Pathogenesis | ||
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==Work-Up== | ==Work-Up== | ||
*Labs | |||
**CBC | |||
**Chemistry | |||
**LFTs | |||
**Lipase | |||
**UA | |||
*Imaging | |||
**CT w/ IV and PO contrast | |||
***Sn 97%, Sp 100% | |||
==Treatment== | ==Treatment== | ||
| Line 52: | Line 52: | ||
==Disposition== | ==Disposition== | ||
===Admit=== | |||
*All complicated diverticulitis | |||
*Intractable [[nausea/vomiting]] | |||
*Comborbid disease | |||
*High WBC, high fever, elderly, immunocompromised | |||
*Failed outpt therapy (worsening symptoms or CT findings within 6 weeks of initial episode) | |||
== | ===Discharge=== | ||
*Well-appearing, immunocompetent patients with 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 | |||
==References== | |||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 10:09, 10 June 2015
Background
- Prevalence of diverticulosis 30% by age 60, >70% by age 85
- 70% of pts w/ 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 (Asia)
- Pathogenesis
- Erosion of diverticular wall by inspissated fecal material leads to microperforation
- Most common pathogens are anaerobes, as well as gram-negative rods
- Erosion of diverticular wall by inspissated fecal material leads to microperforation
- 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
Differential Diagnosis
LLQ Pain
- Diverticulitis
- Kidney stone
- UTI
- Pyelonephritis
- Ectopic pregnancy
- Infectious colitis
- Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
- Inguinal hernia
- Mesenteric ischemia
- Epiploic appendagitis
- Mittelschmerz
- Ovarian cyst
- Ovarian torsion
- PID
- Psoas abscess
- Testicular torsion
- Appendicitis
- Abdominal aortic aneurysm
- Herpes zoster
- Endometriosis
- Colon cancer
- Irritable bowel syndrome
- Small bowel obstruction
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
- Labs
- CBC
- Chemistry
- LFTs
- Lipase
- UA
- Imaging
- CT w/ IV and PO contrast
- Sn 97%, Sp 100%
- CT w/ IV and PO contrast
Treatment
- Antibiotics are aimed at treating Gram Negative organisms and Anerobes (Enterobacteriaceae, Pseudomonas aeruginosa, Bacteriodes sp., and Enterococci)[2]
Uncomplicated
- Liquid diet and bowel rest are most important
Antibiotic Options:
- Metronidazole 500mg PO Q8hrs AND Ciprofloxacin 500mg PO BID x5days
- Amoxicillin/Clavulanate 875/125 PO Q8hrs x5days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[3][4]
- Trimethoprim/Sulfamethoxazole, one double-strength tablet bid, and Metronidazole 500 mg Q8h
- Moxifloxacin 400mg PO QDaily[5]
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.[6]
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 Options:
- Ticarcillin/Clavulanate 3.1 g IV Q6h or
- Piperacillin/Tazobactam 3.375 g IV q6 hours x 7-10 days
- Ciprofloxacin 400 mg IV q12h and metronidazole 1 g IV Q12h
- Ampicillin 2 g IV Q6h and Metronidazole 500 mg IV q6h Plus (Gentamicin 7 mg/kg Q24h or Ciprofloxacin 400 mg IV Q12h)
- Imipenem 500 mg IV Q6h
Disposition
Admit
- All complicated diverticulitis
- Intractable nausea/vomiting
- Comborbid disease
- High WBC, high fever, elderly, immunocompromised
- Failed outpt therapy (worsening symptoms or CT findings within 6 weeks of initial episode)
Discharge
- Well-appearing, immunocompetent patients with 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
References
- ↑ 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.
- ↑ Tursi, A. et al. Diverticular disease: A therapeutic overview. World J Gastrointest Pharmacol Ther. Feb 6, 2010; 1(1): 27–35
- ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
- ↑ 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
- ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
- ↑ 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