Best Dx/Best Rx: Diverticulitis

From: Subject: Best Dx/Best Rx: Diverticulitis Date: Wed, 3 Jun 2009 21:16:54 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0160_01C9E490.9EAEF720" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0160_01C9E490.9EAEF720 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0412.htm Best Dx/Best Rx: Diverticulitis

Diverticulitis

William V. Harford, Jr., M.D.
University of = Texas=20 Southwestern Medical Center

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition

Inflammation of diverticula=20
- Small herniations of colonic mucosa and = submucosa=20 through the muscularis propria=20
- Occurs in 10%=9625% of patients with known=20 diverticulosis

Key Clinical Features

Abdominal pain and localized tenderness, = usually in left=20 lower quadrant=20
Anorexia=20
Nausea without vomiting=20
Diarrhea or constipation caused by colonic=20 inflammation=20
Low-grade fever=20
Complications
- Phlegmon=20
- Abscess=20
- Perforation=20
- Bacteremia=20
- Sepsis syndrome=20
- Fistula formation =

bac= k to=20 top

Differential = Diagnosis

General Population

Appendicitis=20
Mesenteric adenitis=20
Crohn disease=20
Meckel diverticulitis=20
Infectious colitis or ileitis=20
Small-bowel obstruction=20
Perforated peptic ulcer=20
Acute cholecystitis=20
Acute pancreatitis=20
Urinary tract infection

Women of Childbearing Age

PID=20
Rupture of ovarian follicle or cyst=20
Ruptured ectopic pregnancy=20
Ovarian torsion

Middle-Aged to Elderly = Patients

Ischemic colitis=20
Perforated cancer of right colon =

Young Children

Intussusception

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Best=20 Tests

If symptoms are mild and respond to empirical = therapy,=20 defer x-rays=20
History and physical exam are often sufficient = for a=20 presumptive diagnosis=20
In women of childbearing age, perform pelvic = and=20 abdominal ultrasound=20
Plain abdominal x-ray to exclude other = abdominal=20 conditions=20
If symptoms are severe, perform the = following:=20
- Plain abdominal x-ray to exclude abdominal = obstruction=20 or perforated bowel=20
- Abdominal CT with oral and I.V. = contrast=20
After acute symptoms have resolved, consider = colonoscopy=20 or barium enema to exclude cancer and inflammatory bowel = disease=20

bac= k to=20 top

Best=20 Therapy

For mild symptoms, recommend liquid diet or = low-roughage=20 diet=20
If symptoms are severe or if there is concern = for=20 intra-abdominal infection, get surgical consultation=20
Antibiotic therapy
High-fiber diet may be useful for = prevention=20

Antibiotic Therapy for = Diverticulitis

Amoxicillin-clavulanate

For mild diverticulitis=20
Dose: 875/125 mg p.o., q. 12 hr=20
Cost/mo: $214.98

Sulfamethoxazole-trimethoprim +=20 Metronidazole

For mild diverticulitis
Dose: 1 double-strength S/T b.i.d. + 500 mg=20 metronidazole p.o., q. 8 hr
Cost/mo: $19.49 + $27.99

Ciprofloxacin + Metronidazole

For mild diverticulitis=20
Dose: 500 mg ciprofloxacin p.o., q. 12 hr, + = 500 mg=20 metronidazole p.o., q. 8 hr=20
Cost/Mo: $445 + $28

Levofloxacin + Metronidaxole

For mild diverticulitis=20
Dose: 750 mg levofloxacin p.o., q. 12 hr, + = 500 mg=20 metronidazole p.o., q. 8 hr=20
Cost/mo: $620 + $28

Ampicillin-sulbactam

For severe/complicated diverticulitis=20
Dose: 1.5=963.0 g I.V. q. 6 hr =

Cephalosporin Alone

For severe/complicated diverticulitis=20
Cefotetan=20
- Dose: 2 g I.V. q. 12 hr
Cefoxetin=20
- Dose: 2 g I.V. q. 6 hr =

Cefotetan + Gentamicin

For severe/complicated diverticulitis=20
Dose: 1 g cefotetan q. 12 hr (or 400=96900 mg = clindamycin=20 q. 8 hr for penicillin-allergic patients) + 5=967.5 mg/kg gentamicin = in single=20 daily dose

Metronidazole + Ceftriaxone

Dose: 500 mg metronidazole I.V. q. 6 hr + 1 g=20 ceftriaxone I.V. q. 24 hr

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Best References

American Society of Colon and Rectal Surgeons: = Dis Colon=20 Rectum 43:289, 2000 [PMID 10733107]

Kaiser AM, et al: Am J Gastroenterol 100:910, = 2005 [PMID=20 15784040]

Macias LH, et al: Am Surg 70:932, 2004 [PMID=20 15529855]

October=20 2006