Diverticulosis is the presence of diverticuli, which may become inflammed (diverticulitis).
See also:
Abdominal pain Ddx
Diverticulosis
Pathophysiology
Inflammation of a diverticulum caused by trapping of particulate matter and/or rupture of the lumen.
Can involve infection of and microperforation of a colonic diverticulum.
May lead to perforation and subsequent abscess formation
Hx
Alternating diarrhea and constipation
Low-fiber, high-fat diet
History of constipation is a risk factor: increased luminal pressure over time causes diverticuli to develop
Sx
Abdominal pain
Fever
Chills
Nausea
Vomiting
Change in bowel habits (constipation or diarrhea) are common
Hematochezia, heme-positive stool are sometimes seen
Perforation/rupture of a peridiverticular abscess may present with peritoneal signs
PE
LLQ pain and tenderness is typical
Workup
CBC, electrolytes
CXR
AXR
CT-abdomen
Rectal exam
Labs
May see leukocytosis
Dx
May be clinical
CT is diagnostic study of choice (demonstrates pericolic inflammation and bowel wall thickening and complications such as peridiverticular abscess)
Hb and Hct key to diagnosing hemorrhage
Tx
Signs of perforation (free air), a complicated abscess or phlegmon, fistula, or obstruction require surgical consultation
Mild disease may be treated safely as outpatient with liquid diet & meds for 48 h, so long as there is no vomiting or evidence of complication
First-line: Ciprofloxacin (500 mg PO bid) + Metronidazole (500 mg PO tid)
Or Metronidazole plus ceftriaxone (IV only)
Or Metronidazole plus Bactrim (PO)
Alternatively: Augmentin 875/125 mg bid is acceptable
If patient intolerant of metronidazole and beta-lactams, consider clindamycin or moxifloxacin.
Signs of toxicity warrant inpatient management: bowel rest (NPO), pain management, IV fluids, IV antibiotics
Must cover bowel flora including E. coli and anaerobes (Bacteroides fragilis).
Generally, 7-14 days of antibiotics are recommended for uncomplicated diverticulitis. Extended exposure to antibiotics is not recommended as it can cause antibiotic-associated diarrhea and Clostridium difficile colitis.
A colonoscopy in 2-6 weeks (after recovery) should be done to explore the full extent of his diverticulosis and rule out colon polyps or cancer. There is no role for waiting a year for colonoscopy.
A high fiber diet will help decrease constipation and intraluminal pressure and may decrease the chance of recurrent diverticulitis.
Counsel patient that approximately 1/3 of patients have recurrent abdominal cramps and 1/3 will have another frank episode of diverticulitis in the future. Some patients with recurrent episodes may require surgery to resect the diseased portion of the bowel.
Diverticulosis and Diverticulitis patient article: http://patients.gi.org/topics/diverticulosis-and-diverticulitis/
