Diverticulitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Overview

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease, causing fever, leukocytosis and lower abdominal pain. It could be simple or complicated, which includes gross or microscopical perforation, obstruction, the formation of abscesses or fistulization.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Diverticulitis is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Diverticular Disease
• Increased intracolonical pressure
• Constipation

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to diverticulitis according to the American Society of Colon and Rectal Surgeons and the American Journal of Gastroenterology

Characterize the symptoms: ❑ Abdominal pain ❑ Lower left quadrant ❑ Abdominal fullness ❑ Fever ❑ Nausea ❑ Vomiting ❑ Pneumaturia ❑ Fecaluria ❑ Pneumaturia ❑ Pyuria
Obtain a detailed history: ❑ Age ❑ Previous history of diverticular disease ❑ Previous episodes of diverticulitis ❑ Chronic Abdominal pain ❑ Previous history of abdominal surgery ❑ Dietary regime ❑ History of: ❑ Irritable bowel syndrome ❑ Inflammatory bowel disease ❑ Colitis ❑ Immunodeficiency
Examine the patient: ❑ Vital signs ❑ Obesity ❑ Abdomen ❑ Tenderness (localized or diffused) ❑ Guarding ❑ Rigidity
Consider alternative diagnoses: ❑ Urinary tract infection ❑ Kidney stones ❑ Bowel obstruction ❑ Irritable bowel syndrome ❑ Appendicitis ❑ Inflammatory bowel disease ❑ Mesenteric ischemia ❑ Malignancy ❑ Gynecological diseases
Order labs: ❑ Complete blood count ❑ Urianalysis Order imaging studies: ❑ CT scan of the abdomen and pelvis ❑ Presence of diverticula ❑ Inflammation of the pericolic fat ❑ Bowel-wall thickness > 4 mm ❑ Peridiverticular abscess ❑ Abdominal X-rays with soluble contrast

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to diverticulitis according to the American Journal of Gastroenterology and the American Society of Colon and Rectal Surgeons

Initial Management

Uncomplicated

Complicated

Outpatient ❑ Inmunocompetence ❑ Tolerated oral intake ❑ Single episode ❑ Mild to moderate pain

Hospitalized ❑ Immunocompromise ❑ Unable to tolerate oral intake ❑ Severe pain

❑Abscess ❑Phlegmon ❑Obstruction ❑Fistulization ❑Bleeding ❑Sepsis

Medical treatment ❑ Administer oral broad spectrum antibiotics for 7 days ❑ Metronidazole (500 mg/ 6-8 hrs) + quinolone (e.g. ciprofloxacin 500 - 750 mg/ 12 hrs) ❑ Metronidazole (500 mg/ 6-8 hrs) + trimethoprim (160 mg / 12 hrs)/sulfamethoxazole (800 mg/ 12 hrs) ❑ Amoxicillin - clavulanate (875 mg/ 12 hrs)

Medical treatment ❑ Administer intravenous broad spectrum antibiotics ❑ Metronidazole (500mg/ 6-8 hrs) + quinolone (e.g. ciprofloxacin 400mg/ 12 hrs) ❑ Metronidazole (500mg/ 6-8 hrs) + third-generation cephalosporin (e.g. ceftriaxone 1-2g / 24 hrs) ❑ Beta-lactam with beta-lactamase inhibitor (e.g. ampicillin sulbactam 3g / 6 hrs) ❑ Keep nothing by mouth ❑ Insert nasogastric tube in case of evidence of obstruction or ileus

Stage the severity by using: ❑ European Association for Endoscopic Surgery clinical Classification ❑ Buckley Classification ❑ Hinchey Classification

❑ No response to treatment in 2-3 days ❑ Worsening of signs and symptoms ❑ Recurrence of attacks ❑ Uncertain diagnosis ❑ Occurrence of complications (fistula, perforation or obstruction)

Mild

Moderate

Severe

❑ Repeat CT scan ❑ Obtain a surgical consult

Hinchey Stage I ❑Small precolic abscess (<4cm in diameter) ❑Without peritonitis

Hinchey Stage II ❑Peridiverticular abscess (>4cm in diameter)

Hinchey Stage III and IV ❑Generalized peritonitis ❑Uncontrolled sepsis ❑Uncontained visceral perforation ❑Large inaccessible abscess

Treat conservatively ❑ Bowel rest ❑Broad - spectrum antibiotics intravenously ❑Pain control

Percutaneous Drainage ❑ Bowel rest ❑Broad - spectrum antibiotics intravenously ❑CT-guided percutaneous drainage ❑Pain control

If patient doesn't respond to treatment

Surgery

Traditional two or three stage surgery

One stage surgical approach if possible (generally after percutaneous drainage)

Laparoscopy surgery if specialist available

European Association for Endoscopic Surgery clinical Classification

Grades	Clinical Description
Grade I symptomatic uncomplicated disease	Fever Abdominal pain
Grade II recurrent symptomatic disease	Recurrence of above
Grade III complicated disease	Abscess Hemorrhage Fistula Phelgmom Perforation Obstruction Purulent and fecal peritonitis

Buckley Classification

	CT Findings
Mild	Bowel wall thickening
Moderate	Bowel wall thickening > 3mm Phelgmon or small abscess
Severe	Bowel wall thickening > 5mm Perforation with subdiaphragmatic free air Abscess > 5mm

Hinchey's Classification

Stages	CT Findings
Stage 1	Small confined precolic or mesenteric abscess
Stage 2	Large abscess confined to the pelvis
Stage 3	Perforated diverticulitis Peridiverticular abscess has ruptured
Stage 4	Free rupture of diverticula into the peritoneal cavity

Do´s

• Do perform colonoscopy and sigmoidoscopy, approximately six weeks after the inflammatory process, in order to rule out other diseases.
• Do insert a nasogastric tube if evidence of obstruction or ileus.
• Do perform a percutaneous drainage if planning for a successful one stage procedure.
• Do perform Laparoscopic surgery, as it tends to shorter hospital stays, less post-operative pain and reduced overall risk of complications.
• Do perform elective surgery after first diverticulitis episode in immunocompromised patients, as they are at higher risk for perforation and abscesses formation.
• Do perform urinalysis and plain abdominal X-rays to differentiate urinary track infections, kidney stones and bowel obstruction.
• Do use ultrasound and MRI are useful alternative in the initial evaluation.
• Do perform percutaneous drainage in patients with fever >101.2°F or abscesses >6.5cm in diameter.
• Do recommend elective single stage colectomy for patients who undergo percutaneous drainage, although decision should be individualized and risk of operative surgery should be considered.
• Do consider the use of ureteral stents in complicated cases such as patients who are morbidly obese, patients who have been irradiated, patients undergoing reoperation or in cases of abnormal anatomy.
• Do consider the administration of non-absorbable oral antibiotics such as erythromycin, neomycin, flagyl and clindamycin before elective color resection as well as mechanical bowel preparation, as they may reduce surgical site complications.
• Do perform emergency surgery on patients with chronic renal failure or collagen vascular disease, as they have high risk of recurrence con complicaed diverticulitis.
• Do perform urgent sigmoid colectomy on patients with diffused peritonitis.

Don'ts

• Do not perform colonoscopy and sigmoidoscopy, when suspecting acute diverticulitis, because of the risk of perforation.
• Do not reverse a colostomy in elderly patients due to the increased risk of anastomotic leakage, small bowel trauma, or incisional herniation.
• Do not recommend elective resection solely on the patients age (<50 years old).
• Do not recommend laparoscopic lavage to patients with purulent or fecal peritonitis.
• Do not perform ultrasounds on patients with abdominal tenderness as it requires compression.

References

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