7 Diverticulitis Flashcards
Remarks on epidemiology of diverticular disease
The prevalence of diverticulosis increases with age
Only 15% of patients with diverticulitis develop complicated disease. (The natural history of the disease appears to be more benign than previously believed.)
Remarks on the management of diverticulitis
- Although surgery played a prominent role in diverticulitis management in the past, most cases of diverticulitis can be managed medically.
- In stable patients with a history of confirmed diverticulitis and a similar acute presentation, no further diagnostic evaluation is necessary unless the patient fails to improve with conservative medical management.
- If a prior diagnosis has not been confirmed or the current episode differs from the past episode, diagnostic imaging is required to exclude other intra-abdominal pathology and to evaluate for complications
Define diverticula
Diverticula are small herniations at site where the vasulature, called vasa recta, penetrates the circular muscle layer of the colon.
Diverticula usually range from 5 to 10 mm, but can extend up to 20 mm in length.
Dominant bacteria isolated in diverticulitis
Bacteroides fragilis and E. coli
Drugs that increase the risk of perforation in diverticulosis.
NSAIDs, opioids, and steroids
Sidedness of diverticular disease
US: diverticular disease is almost exclusively a left-sided colon disease, specifically the descending and sigmoid colon
Asian: Right-sided disease is found predominantly in Asian populations
Schwartz: Right-sided diverticula occur more often in younger patients than do left-sided diverticula adn are *more common in people of Asian descent than in other populations*
Pain in diverticulitis
The pain may be intermittent or constant
and is often assoc’d with a change of bowel habits, either diarrhea or constipation.
Preferred imaging modality for diverticulitis
Abdominopelvic CT with IV contrast
CT is also preferred to detect complications.
CT findings of diverticulitis
Increased soft tissue density within the pericolic fat (inflammation)
Presence of diverticula
Bowel wall thickening >4 mm
Soft tissue masses representing phlegmon
Pericolic fluid collections representing abscesses
The 2015 American Gastroenterology Association recommendation on treatment of acute uncomplicated diverticulitis.
“that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis” confirmed by CT.
With increased understanding of the inflammatory rather than infectious etiology of uncomplicated diverticulitis, recent studies have reported no benefit to routine antibiotic use
Remarks on use of antibiotics in diverticulitis
- If antibiotics are warranted, a shorter duration of antibiotics (4 to 5 days) compared to the standard antibiotic course (7 to 10 days) may be appropriate)
- There is no proven advantage of IV antibiotics over PO antibiotics for diverticulitis
First line antibiotics for outpatient management
Metronidazole 500 mg PO QID
PLUS
Ciprofloxacin 750 mg PO BID
OR
Levofloxacin 750 mg PO daily
OR
Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1 double-strength tablet PO BID
OR
Cefuroxime 500mg PO BID
Alternate antibiotics for outpatient management
Amoxicillin-clavulanate 875 mg 1 tab PO BID
OR
Moxifloxacin 400mg PO daily
First line antibiotics for Moderate disease
Metronidazole 500mg IV q6h or 1g IV q12
PLUS
Cprofloxacin 400mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Aztreonam 2g IV tID
OR
Ceftriaxone 1-2g IV q24h
OR
Cefuroxime 1.5g IV q8h
Alternate antibiotics for Moderate disease
Ertapenem 1 g IV q24h
Pip-taz 3.375 g IV q6h or 4.5 g IV q8h
Ticarcillin-clavulanate 3.1 g IV q6
First line antibiotics for severe, life-threatening diverticulitis
Imipenem/cilastatin 500mg IV q6h
OR
Meropenem 1g IV q8h
OR
Pip-taz 4.5 mg IV q8h
OR
Ticarcillin-clavulanate 3.1 g IV q4h
Alternate antibiotics for severe, life-threatening diverticulitis
Ampicillin 2g IV q6h
PLUS
Metronidazole 500mg IV q6h
PLUS
Ciprofloxacin 400mg IV q12h
OR
Amikcacin 15 mg/kg/day IV divided q12h
Alternate antibiotics for severe, life-threatening diverticulitis with penicillin-allergy
Aztreonam 2g IV q6h
PLUS
Metronidazole 500mg IV q6h
Dietary recommendations in diverticulitis
- It is not necessary to limit the patients to a clear diet, but patients can be advised to eat foods as tolerated.
- During the acute episode, our personal recommendations also include no dairy foods, because ability to process lactate can change, and no red meat, because it is difficult to digest
Complicated diverticulitis is classified by
Hinchey classification scheme
Stage 1: small (<3 cm), confined pericolic or mesenteric abscesses
Stage 2: larger abscesses, extending to the pelvis
Stage 3: perforated diverticulitis and purulent peritonitis
Stage 4: free perforation with fecal contamination of the peritoneal cavity
Phlegmon is
inflammation and infection of tissue without abscess
Patients who can follow up with physician in _______ days are candidates for outpatient management +/- antibiotics
2-3 days
Those who require inpatient management are
Those with complicated diverticulitis
- phlegmon
- abscess
- perforation
- fistula
- stricture
- obstruction
High-risk patients
Some clinical high risk factors
Fever
Active malignancy
Chronic opiate use
Corticosteroid use
Diagnostic high risk factors
Generalized abdominal pain/ternderness
Leukocytosis - WBC 11,000
CRP >9 mg/dL
Signs of sepsis
CT imaging high risk factors for progression to complicated diverticulitis
Fluid collections (frequently anterior to rectum)
Greater length of inflamed colon (85 mm vs 65 mm)
Inflamed diverticulum greater than 2 cm
