Diverticulitis resident survival guide

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

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

References

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