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The typical presentation of acute diverticulitis varies depending on the stage of disease and patient characteristics. The patient may have isolated mild tenderness in the left lower quadrant or full-blown peritonitis. Often times, the patient has a prior history of similar episodes or objective evidence from prior colonoscopies of diverticulosis. The exam in diverticulitis can vary. In mild and early disease in which there is a contained microperforation, there may be minimal tenderness in the left lower quadrant. If the process has extended beyond a contained perforation, there may be more severe or diffuse tenderness or peritonitis. Acquired diverticula are actually false diverticula (i.e., they do not contain all the layers of the bowel wall) and form when the submucosa and mucosa (the inner most two layers of the bowel wall) herniate through the muscular wall of the bowel. This occurs at areas of intrinsic weakness in the bowel where the vasculature enters. This association with vasculature is the reason some patients with diverticulosis experience colonic bleeding. Diverticulitis is the condition in which one or more of these outpouchings perforate (usually a microperforation), causing leakage of colonic material into the surrounding area, leading to localized inflammation with infection or diffuse peritonitis. The reason most cases of diverticulitis do not present with free perforation is that the diverticula initially protrude into the mesentery of the colon or into the appendices epiploicae, which contain the microperforation. Patients must have diverticulosis to develop diverticulitis. Age is an important risk factor; older adults have a higher incidence of diverticulosis. However, more recently and likely because of popularization of westernized diets, many patients are developing diverticulosis at an earlier age, putting them at risk of subsequent episodes of acute diverticulitis. Low fiber diet is considered a risk factor for diverticular disease, leading to smaller, harder stools that require higher colonic pressures for transit. This pressure leads to formation of more diverticula and a potentially higher chance of perforation. The greatest risk factor for diverticulitis is having had a previous episode of diverticulitis, with around 20% of those treated non-surgically having a repeated episode requiring hospital admission. Early or mild diverticulitis may present similarly to gastroenteritis or a urinary tract infection (UTI) with mild abdominal tenderness. If free perforation with peritonitis occurs, the differential diagnosis includes all causes of acute abdomen (e.g., perforated ulcers, perforated appendicitis, biliary tract disease, urinary tract disease, inflammatory bowel disease, ovarian torsion, ectopic pregnancy, Meckel’s diverticulum, etc.). It is important to recognize that any disease process that leads to colonic perforation, the most important of which is perforated colon cancer, mimics diverticulitis. This is especially important as both disease processes are more likely to occur in older adults. There will usually be an elevated white blood cell (WBC) count and left shift, although patients with early and mild diverticulitis may have a normal WBC count. This result may be blunted in the elderly or immunocompromised. Urinalysis should be ordered to rule out a urinary tract source of pain, keeping in mind that a colo-vesical fistula will also cause a UTI. Patients in whom operative intervention is a possibility should have basic chemistries and coagulation studies. There is no specific laboratory test that will confirm the diagnosis of diverticulitis. CT scan of the abdomen and pelvis (estimated cost $2000) is very useful in diverticulitis with sensitivity and specificity reported as high as 98 and 99%. CT scan can not only confirm the diagnosis, but will also provide information about the extent of extra-colonic involvement and involvement of other organs. It is also useful in revealing other possible sources for pain. In some cases of diverticulitis, it also provides a roadmap for percutaneous placement of drainage catheters for abscess treatment. CT scans can also be very useful to rule out the diagnosis of diverticulitis in patients who have a compatible clinical presentation but no signs of inflammation of the colon on routine imaging. Plain films of the abdomen (estimated cost $300) can be obtained and may show free air or pneumoperitoneum in the case of free perforation. Barium enema (estimated cost $200) was once widely used to examine the colon in cases of diverticulitis; now, it is avoided because of the risk of extending the degree of perforation. Colonoscopy is useful in the non-inflamed colon (once the acute inflammatory process has resolved, typically 4-6 weeks after medical treatment of the acute episode) to determine the presence and location of diverticula, but it is contraindicated in the setting of acute inflammation because of risk of extending the degree of perforation. Previous studies, such as barium enema and/or colonoscopy, should be reviewed to determine whether the patient had diverticula and their location. Any patient admitted with diverticulitis should have a surgical consultation. If you decide the patient has diverticulitis, what therapies should you initiate immediately? In 1978, Hinchey described four stages of diverticulitis, and this classification is still used today to help determine the extent of the infectious process and guide therapy:
This classification system was modified by Sher in 1997 and Wavery in 1999: Adding a stage 0: mild disease. Dividing stage I into Ia and Ib: Ia being confined pericolic inflammation and Ib being confined pericolic abscess. Dividing stage II into IIa and IIb: IIa being abscess amenable to percutaneous drainage and IIb being complex abscess with possible fistula. Using clinical exam and imaging (CT scan) to stratify patients into these groups may be helpful when deciding on treatment. In stage 0 and stage Ia, antibiotic treatment alone is usually adequate. In mild cases in patients tolerating an oral diet, this treatment may be given with oral antibiotics on an outpatient basis. In stages Ib, IIa, and IIb, a combination of IV antibiotics +/- percutaneous drainage (for abscesses greater than 3cm) is usually attempted, with surgery reserved for those who fail to improve or develop peritonitis. In stages III and IV, surgical resection is usually required to control the intra-abdominal spillage and inflammation (source control). Historically, this operation has been done in two stages with resection of the diseased colon and drainage of all infectious material, along with formation of a temporary ostomy, followed by a second stage in which re-anastomosis of the colon after the inflammation has resolved is performed (usually >6 weeks following the initial surgery). More recent studies have shown similar outcomes after a single surgery during which the diseased colon is removed and the remaining colon is anastomosed together in one step, in well selected patients. These studies are almost all retrospective and may have a large amount of selection bias. One small randomized controlled trial compared a two stage approach with end colostomy followed by colostomy takedown to patients who underwent primary anastomosis with diverting loop ileostomy followed by ileostomy takedown. Although outcomes after the first surgery were similar, patients who underwent primary anastomosis and loop ileostomy were more likely to have their ostomy reversed and had fewer complications during the second surgery. This is still an area of controversy and surgical decision making should be individualized to the patient and to the surgeon’s experience with these often complicated procedures. In addition, there has been recent interest in laparoscopic lavage as a definitive treatment for Hinchey III diverticulitis. Evidence from recent randomized trials has been mixed, with one small trial favoring lavage with shorter hospitalization times and fewer reoperations and another showing a higher rate of reoperations in the lavage group. At this time there is not sufficient evidence to recommend laparoscopic lavage for as treatment for severe diverticulitis. 1. Anti-infective agentsIf I am not sure what pathogen is causing the infection what anti-infectives should I order?
Diverticulitis cannot be prevented, but all patients should be encouraged to eat food that is high in fiber to bulk up stools and decrease the amount of colonic pressure needed for transit. WHAT'S THE EVIDENCE for specific management and treatment recommendations?Alonso, S, Pera, M, Pares, M. “Outpatient treatment of patients with uncomplicated acute diverticulitis”. Colorectal Dis. vol. 12. 2010. pp. 278-2. Anaya, DA, Flum, DR. “Risk of emergency colectomy and colostomy in patients with diverticular disease”. Arch Surg. vol. 140. 2005. pp. 681-5. Beckham, H, Whitlow, CB. “The medical and non-operative treatment of diverticulitis”. Clin Colon Rectal Surg. vol. 22. 2009. pp. 156-60. Beilman, G. “Controversies in the diagnosis and management of diverticulitis coli”. Surg Infect. vol. 12. 2011. pp. 231-4. Chabok, A, Pahlman, L, Hjern, F. “Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis”. Brit J Surg. vol. 99. 2012. pp. 532-9. (This is a multicenter clinical trial that randomized patients to receive antibiotics vs. no antibiotic treatment for acute uncomplicated diverticulitis.) Commane, DM, Arasaradnam, RP, Mills, S. “Diet, ageing, and genetic factors in the pathogenesis of diverticular disease”. World J Gastroenterol. vol. 15. 2009. pp. 2479-88. deKorte, N, Unlu, C, Boermeester, MA. “Use of antibiotics in uncomplicated diverticulitis”. Brit J Surg. vol. 98. 2011. pp. 761-7. Feingold, D, Steele, S, Lee, S. “Practice parameters for the treatment of sigmoid diverticulitis”. Dis Colon Rectum. vol. 57. 2014. pp. 284-94. (These practice parameters were developed by the clinical practice guideline taskforce for the American Society of Colon and Rectal Surgeons and provide a good overview of the current surgical management of diverticulitis.) Hinchey, EJ, Schaal, PG, Richards, GK. “Treatment of perforated diverticular disease of the colon”. Adv Surg. vol. 12. 1978. pp. 85-109. Klarenbeek, BR, Korte, N, van der Peet, DL. “Review of current classifications for diverticular disease and a translation into clinical practice”. Int J Colorectal Dis. vol. 27. 2012 Feb. pp. 207-14. Kotzampassakis, N, Pittet, O, Schmidt, S. “Presentation and treatment outcomes of diverticulitis in younger adults: a different disease than in older patients”. Dis Colon Rectum. vol. 53. 2010. pp. 333-8. Martel, J, Raskin, JB. “History, incidence, and epidemiology of diverticulosis”. J Clin Gastroenterol. vol. 42. 2008. pp. 1125-27. Oberkofler, C, Rickenbacher, A, Raptis, D. “A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or feculent peritonitis”. Annals of Surgery. vol. 256. 2012. pp. 819-27. (A recent multicenter clinic trial comparing complications after colonic resection with primary anastomosis and diverting ileostomy versus Hartmann's procedure in Hinchey III and IV diverticulitis.) Ritz, JP, Lehmann, KS, Frericks, B. “Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation”. Surgery. vol. 149. 2011. pp. 606-13. Sarma, D, Longo, WE. “Diagnostic imaging for diverticulitis”. J Clin Gastroenterol. vol. 42. 2008. pp. 1139-41. Schultz, J, Yaqub, S, Wallon, C. “Laparoscopic lavage vs primary resection for acute perforated diverticulitis”. JAMA. vol. 314. 2015. pp. 1364-75. (A recent multicenter randomized clinic trial examining severe post-operative complications after laparoscopic peritoneal lavage vs. colon resection for perforated diverticulitis.) Shabanzadeh, DM, Wille-Jørgensen, P. “Antibiotics for uncomplicated diverticulitis (review)”. Cochrane Database of Systematic Reviews 2012. vol. 11. (This is a comprehensive review of randomized controlled trials examining antibiotic treatment for left sided uncomplicated diverticulitis.) Solomkin, JS, Mazuski, JE, Bradley, JS. “Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the surgical infection society and the infectious diseases society of America”. Surg Infect. vol. 11. 2010. pp. 79-109. Strate, LL, Liu, YL, Syngal, S. “Nut, corn, and popcorn consumption and the incidence of diverticular disease”. JAMA. vol. 300. 2008. pp. 907-14. Thornell, A, Angente, E, Bisgaard, T. “Laparoscopic lavage for perforated diverticulitis with purulent peritonitis, a randomized trial”. Ann Intern Med. vol. 164. 2016. pp. 137-145. (This is a recent small randomized trial that compared laparoscopic lavage to open colon resection and colostomy in patients with Hinchey III diverticulitis.) DRG CODES and expected length of stay329-331 (surgical) and 371-373 (medical) The expected length of stay is quite variable, ranging from 2-5 days for uncomplicated diverticulitis to weeks or more for complicated cases that may require multiple procedures or surgeries. Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. The Licensed Content is the property of and copyrighted by DSM.
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