Diverticulitis resident survival guide

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

Definition

Diverticulitis, is the inflammation of the diverticula present in the diverticular disease. It could be simple or complicated, which includes perforation, obstruction, fistulization or the formation of abscesses.

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 or preirectal fullness ❑ Fever ❑ Leukocytosis ❑ Nausea ❑ Vomits ❑ 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: ❑ Ectoscopy: ❑ Obesity ❑ Measure the heart rate ❑ Measure the temperature ❑ Abdomen: ❑ Rigidty ❑ Tendernes
Order labs and tests: ❑ CT ❑ Blood Count: ❑ Leukocytes ❑ Abdominal X-rays with soluble contrast ❑ Urianalysis

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 ❑ Inmunocompetent patient ❑Tolerated oral intake ❑Single episode ❑Mild to moderate pain

Hospitalized ❑Unable to tolerate oral intake ❑Severe pain ❑Inmunocompromised patients

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

Medical Treatment Oral regimens ❑Metronidazole (500mg / 6 - 8 hrs) + Quinolone (e.g. Ciprofloxacin 500 - 700mg / 12hrs) ❑Metronidazole (500mg / 6 - 8 hrs) + Trimethoprim (160mg / 12 hrs) - Sulfamethoxazole (800mg / 12hrs) ❑Amoxicillin- clavulanate (875mg / 12hrs)

Medical Treatment Intravenous regimen ❑Metronidazole (500mg / 6 - 8 hrs) + Quinolone (e.g. Ciprofloxacin 400mg / 12hrs) ❑Metronidazole (500mg / 6 - 8 hrs) + Third-generation cephalosporin (e.g. Ceftriaxone 1 - 2g / 12hrs) ❑Beta-lactam with Beta-lactamase inhibitor (e.g. Ampicillin sulbactam 3g / 6hrs)

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

If after 2 to 3 days patient: ❑ Doesn't respond to treatment ❑ Repeat episodes ❑ Complicates

Mild

Moderate

Severe

Surgical Consultation

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

❑ 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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