DIVERTICULITIS

Question 1

What is a diverticulum

Answer 1

• sac-like protrusion of the colonic wall

- may be asymptomatic or symptomatic.

Question 2

What is a Diverticulitis

Answer 2

inflammation of a diverticulum.

Question 3

Pertinent Anatomy of a patient with Diverticulitis.

Answer 3

Large intestine

Question 4

Symptoms

Answer 4

(1) Perforation of a colonic diverticulum results in an intra-abdominal infection that may vary from microperforation (most common) with localized paracolic inflammation to macroperforation with either abscess or generalized peritonitis.
(2) mild to moderate aching abdominal pain, usually in the left lower quadrant.
(3) Constipation or loose stools
(4) Nausea and vomiting
(5) low-grade fever, left lower quadrant tenderness, and a possible palpable mass.
(6) Stool occult blood is common, but hematochezia is rare.
(7) Leukocytosis is mild to moderate.
(8) Patients with perforation present with a more dramatic picture of generalized abdominal pain and peritoneal signs.

Question 5

Differential Diagnosis

Answer 5

(a) Perforated colonic carcinoma
(b) Crohn’s disease
(c) Left sided Appendicitis
(d) Ischemic colitis
(e) C difficile-associated colitis
(f) Nephrolithiasis
(g) Pyelonephritis
(h) Gynecologic disorders (ectopic pregnancy, ovarian cyst or torsion)

Question 6

Lab

Answer 6

(1) CBC w/diff

(2) Occult blood

Question 7

RAD

Answer 7

(1) In patients with mild symptoms and a presumptive diagnosis of diverticulitis, empiric medical therapy is started without further imaging in the acute phase.
(2) Patients who respond to acute medical management should undergo complete colonic evaluation with colonoscopy after resolution of clinical symptoms to corroborate the diagnosis or exclude other disorders such as colonic neoplasms.

Question 8

Treatment

Answer 8

(2) Patients with mild symptoms and no peritoneal signs may be managed initially as outpatients on a clear liquid diet and broad-spectrum oral antibiotics with anaerobic activity.
Dual therapy is required:
(a) Amoxicillin and clavulanate potassium (Augmentin) OR Metronidazole (Flagyl) PLUS either Ciprofloxacin (Cipro) OR trimethoprimsulfamethoxazole (Bactrim), for 7-10 days or until the patient is afebrile for
3-5 days.
1) Amoxicillin/clavulanate potassium (Augmentin) - a PCN antibiotic
a) Dose: 875/125 mg PO BID
2) Metronidazole (Flagyl) - is an antibiotic with cytotoxic effects towards anaerobic organisms
a) Dose: 500mg PO TID
3) Ciprofloxacin (Cipro) - is a Fluoroquinolone antibiotic
a) Dose: 500mg PO BID
4) Trimethoprim/sulfamethoxazole (Bactrim) - is a Sulfonamide antibiotic
a) Dose: 160 mg TMP PO BID
(b) Symptomatic improvement usually occurs within 3 days, at which time the diet may be advanced.
(c) Patients with increasing pain, fever, or inability to tolerate oral fluids require
hospitalization.
(3) Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) and patients who are elderly or immunosuppressed or who have serious comorbid disease require hospitalization acutely.
(a) Patients should be given nothing by mouth and should receive intravenous
fluids.
(b) If ileus is present, a nasogastric tube should be placed.
(c) Intravenous antibiotics should be given to cover anaerobic and gram-negative
bacteria. Single agent and combination therapy appear to be equally effective.
(4) Diverticulitis recurs in 10-30% of patients treated with medical management.
(5) Recurrent attacks warrant elective surgical resection, which carries a lower morbidity and mortality risk than emergency surgery

Question 9

Disposition

Answer 9

MEDEVAC

Question 10

Initial Care

Answer 10

Upon patient presentation and inclination of diverticulitis, treat patient to stabilize and prepare for MEDEVAC