Diverticulitis Flashcards
True or false
prevalence of diverticulosis increases with age: 5% in patients age <40 years, 30% by age 60, and >70% by age 85
True
True or false
most cases of diverticulitis can be managed medically, even with recurrent episodes
True
Diverticula are what?
small herniations at sites where the vasculature, called vasa recta, penetrates the circular muscle layer of the colon
true diverticula involve all layers of the colon wall, most acquired diverticula are considered false diverticula, involving only the ________ and _________ layers.
mucosal and submucosal layers
What are the dominant bacteria isolated?
Bacteroides fragilis and E. coli
True or false
Altered bowel motility leads to high intraluminal colonic pressures and diverticula formation.
True
True or false
NSAIDs, opioids, and steroids increase the risk of perforation
True
True or false
In the United States, diverticular disease is almost exclusively a left- sided colon disease, specifically the what part?
descending and sigmoid colon
True or false
Right-sided disease accounts for only 2% to 5% of cases and is found predominantly in Asian populations.
True
preferred imaging modality because of its ability to evaluate the severity of disease and the presence of complications
CT of abdomen and pelvis with IV contrast
CT findings include
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.
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
True
True
Procalcitonin has been suggested as a tool to guide the use of antibiotics in diverticulitis
True
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.
True
Antibiotics for Diverticulitis
Outpatient
First line
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
Antibiotics for Diverticulitis
Outpatient
Alternate
Amoxicillin-clavulanate 875 milligrams 1 tablet PO BID OR
Moxifloxacin 400 milligrams PO daily
Antibiotics for Diverticulitis
Severe, life- threatening
First line
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
Antibiotics for Diverticulitis
Severe, life-threatening
Penicillin allergy
Aztreonam 2 grams IV q6h
PLUS
Metronidazole 500 milligrams IV q6h
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.
True
True or false
Complicated diverticulitis generally requires admission. In addition to bowel rest and IV antibiotics, treatments directed at specific complications
True
Complicated diverticulitis
Hinchey classification scheme:
refers to free perforation with fecal contamination of the peritoneal cavity
STAGE 4
Complicated diverticulitis
Hinchey classification scheme
Perforated diverticulitis and purulent peritonitis
Stage 3
Complicated diverticulitis
Hinchey classification scheme
larger abscesses, extending to the pelvis
STAGE 2
Complicated diverticulitis
Hinchey classification scheme
Small, confined pericolic or mesenteric abscesses
STAGE 1
What are among the most common complications?
Abscesses and phlegmon
Inflammation and infection of tissue without abscess.
Phlegmon
Disposition Options for Diverticulitis
Appropriate for Outpatient Management +/- antibiotics
• 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
Disposition Options for Diverticulitis
Inpatient Management
• Complicated diverticulitis (phlegmon, abscess, perforation, fistula, stricture, obstruction)
• High-risk patients
High Risk of Complications and Treatment Failure
CT Imaging 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
High Risk of Complications and Treatment Failure
Diagnostic Risk Factors
• 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
High Risk of Complications and Treatment Failure
Clinical Risk Factors
• 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
