Diverticulitis

Question 1

True or false

prevalence of diverticulosis increases with age: 5% in patients age <40 years, 30% by age 60, and >70% by age 85

Answer 1

True

Question 2

True or false

most cases of diverticulitis can be managed medically, even with recurrent episodes

Answer 2

True

Question 3

Diverticula are what?

Answer 3

small herniations at sites where the vasculature, called vasa recta, penetrates the circular muscle layer of the colon

Question 4

true diverticula involve all layers of the colon wall, most acquired diverticula are considered false diverticula, involving only the ________ and _________ layers.

Answer 4

mucosal and submucosal layers

Question 5

What are the dominant bacteria isolated?

Answer 5

Bacteroides fragilis and E. coli

Question 6

True or false

Altered bowel motility leads to high intraluminal colonic pressures and diverticula formation.

Answer 6

True

Question 7

True or false

NSAIDs, opioids, and steroids increase the risk of perforation

Answer 7

True

Question 8

True or false

In the United States, diverticular disease is almost exclusively a left- sided colon disease, specifically the what part?

Answer 8

descending and sigmoid colon

Question 9

True or false

Right-sided disease accounts for only 2% to 5% of cases and is found predominantly in Asian populations.

Answer 9

True

Question 10

preferred imaging modality because of its ability to evaluate the severity of disease and the presence of complications

Answer 10

CT of abdomen and pelvis with IV contrast

Question 11

CT findings include

Answer 11

increased soft tissue density within the pericolic fat, indicating inflammation;

presence of diverticula;

bowel wall thickening >4 mm;

soft tissue masses representing phlegmon; or

pericolic fluid collections representing abscesses.

Question 12

True or false

observational treatment without antibiotics may be appropriate for CT-confirmed, uncomplicated, acute diverticulitis in immunocompetent patients with mild symptoms and without systemic infectious signs or symptoms or red flags for progression to complicated diverticulitis

Answer 12

True

Question 13

True

Procalcitonin has been suggested as a tool to guide the use of antibiotics in diverticulitis

Answer 13

True

Question 14

True or false

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.

Answer 14

True

Question 15

Antibiotics for Diverticulitis

Outpatient

First line

Answer 15

Metronidazole 500 milligrams PO QID

PLUS

Ciprofloxacin 750 milligrams PO BID OR
Levofloxacin 750 milligrams PO daily OR
Trimethoprim-sulfamethoxazole (160 milligrams/ 800 milligrams) 1 double-strength tablet PO BID OR
Cefuroxime 500 milligrams PO BID

Question 16

Antibiotics for Diverticulitis

Outpatient

Alternate

Answer 16

Amoxicillin-clavulanate 875 milligrams 1 tablet PO BID OR
Moxifloxacin 400 milligrams PO daily

Question 17

Antibiotics for Diverticulitis

Severe, life- threatening

First line

Answer 17

Imipenem/cilastatin 500 milligrams IV q6h OR
Meropenem 1 gram IV q8h OR
Piperacillin-tazobactam 4.5 milligrams IV q8h OR
Ticarcillin-clavulanate 3.1 grams IV q4h

Question 18

Antibiotics for Diverticulitis

Severe, life-threatening

Penicillin allergy

Answer 18

Aztreonam 2 grams IV q6h
PLUS
Metronidazole 500 milligrams IV q6h

Question 19

True or false

for stable, immunocompetent patients with established follow-up in 2 to 4 days, a short course of anti- biotics (4 to 5 days) may be appropriate.

Answer 19

True

Question 20

True or false

Complicated diverticulitis generally requires admission. In addition to bowel rest and IV antibiotics, treatments directed at specific complications

Answer 20

True

Question 21

Complicated diverticulitis
Hinchey classification scheme:

refers to free perforation with fecal contamination of the peritoneal cavity

Answer 21

STAGE 4

Question 22

Complicated diverticulitis

Hinchey classification scheme

Perforated diverticulitis and purulent peritonitis

Answer 22

Stage 3

Question 23

Complicated diverticulitis
Hinchey classification scheme

larger abscesses, extending to the pelvis

Answer 23

STAGE 2

Question 24

Complicated diverticulitis
Hinchey classification scheme

Small, confined pericolic or mesenteric abscesses

Answer 24

STAGE 1

Question 25

What are among the most common complications?

Answer 25

Abscesses and phlegmon

Question 26

Inflammation and infection of tissue without abscess.

Answer 26

Phlegmon

Question 27

Disposition Options for Diverticulitis

Appropriate for Outpatient Management +/- antibiotics

Answer 27

• Uncomplicated diverticulitis
• Normal vital signs
• Mild to moderate symptoms with mild tenderness on physical exam
• No associated abdominal distention
• No vomiting, able to tolerate fluids and take medications
• Able to control pain with oral medications
• Able to follow up with physician in 2–3 days
• Able to care for self at home

Question 28

Disposition Options for Diverticulitis

Inpatient Management

Answer 28

• Complicated diverticulitis (phlegmon, abscess, perforation, fistula, stricture, obstruction)
• High-risk patients

Question 29

High Risk of Complications and Treatment Failure

CT Imaging Risk Factors for Progression to Complicated Diverticulitis

Answer 29

• Fluid collections (frequently anterior to rectum)
• Greater length of inflamed colon (85 mm vs. 65 mm)
• Inflamed diverticulum greater than 2 cm

Question 30

High Risk of Complications and Treatment Failure

Diagnostic Risk Factors

Answer 30

• Generalized abdominal pain/tenderness versus localized to left lower quadrant
• Leukocytosis – WBC 11 × 109/L (sensitivity 82%, specificity 45%)
• CRP >90 mg/L (sensitivity 88%, specificity 75%)
• Signs of sepsis

Question 31

High Risk of Complications and Treatment Failure

Clinical Risk Factors

Answer 31

• Age >70 years
• Fever
• Vomiting/Inability to tolerate PO
• Poor follow-up or inability to care for self at home
• Multiple comorbid conditions
• Immunocompromised
• Corticosteroid use
• Malnutrition
• Active malignancy
• Chronic opiate use