SX | DX |
Diverticulitis occurs in up to 20% of persons with diverticulosis. It is
caused by inflammation of a diverticulum in response to inspissated fecal
material. Diverticulitis most commonly presents as localized peridiverticulitis
contained by pericolonic fat and mesentery but with the potential for extension
resulting in pericolonic abscess, fistulization, or, rarely, perforation
Fully developed diverticulitis is characterized by acute lower abdominal
pain (usually in the left lower quadrant), accompanied by a change in bowel
habits (diarrhea or constipation), nausea, or vomiting, fever, and tachycadia.
Dysuria, urinary frequency, or pneumaturia reflect inflammatory or fistulous
extension to the bladder.
Physical signs include abdominal tenderness with or without an inflammatory
mass, diminished bowel sounds, or abdominal distention according to the degree
of obstruction. . The patient may present with an acute abdomen; more typically,
symptoms evolve over several hours or days. A mass in the lower abdomen may
connote an abscess or inflammatory phlegmon. Bowel sounds may be active if
partial or complete obstruction has occurred, or they may be hypoactive or
absent if peritonitis has developed. A rectal examination may help to localize
the abscess or inflammatory mass.
Plain abdominal x-ray films, both supine
and upright, should be obtained. Air-fluid levels suggest ileus or obstruction.
Free air in the abdomen, indicating a perforated diverticulum, may be evident
on lateral decubitus abdominal films or under the diaphragm on the upright
chest x-ray film.
CT scan or Ultrasonography of the abdomen
and pelvis is helpful in identifying the inflammatory mass or an abscess
cavity and by demonstrating other conditions in the differential diagnosis,
such as an ovarian cyst.
Sigmoidoscopy and barium enema x-ray examination to confirm the diverticular
disease is best delayed until acute symptoms have subsided.
The differential diagnosis:
inflammatory bowel disease, ischemic colitis, carcinoma of the colon, other
causes of bowel obstruction, gynecologic disorders (e.g., ruptured ovarian
cyst), and urologic disorders (e.g., renal colic).
nothing by mouth; performing nasogastric
suction as indicated, and administering intravenous fluids and electrolytes.
Broad-spectrum antibiotics, such as
the combination of ampicillin 2 gm q6h, gentamicin
1-1.7 mg/kg q8h or single dose regimen, and metronidazole 500 mg
q6h, are indicated and should be continued for 7-10 days.
Other antibiotic regimens for moderate to severe diverticulitis:
Cefoxitin (Mefoxin) 2 gm IV q8h, or Ceftizoxime (Cefizox) 2 g q8h, or
Imipenem-cilistatin (Primaxin) 500 mg q6h
Ceftriaxone (Rocephin) 2 gm IV daily + Metronidazole 500 mg q6h (or Clindamycin
900 mg q8h IV)
Cefotaxime 2 gm IV q8h + Metronidazole 500 mg q6h (or Clindamycin 900 mg
Oral Antibiotic regimens for mild diverticulitis:
PO Ciprofloxacin 500 mg bid + Metronidazole 500 mg tid,
PO Septra DS bid + Metronidazole 500 mg tid,
PO Augmentin (Amoxicillin-clavulanate) 500 mg tid + Tetracycline 500 mg qid
Percutaneous abscess drainage under
ultrasound or computed tomographic (CT) guidance should be considered if
an abscess is identified by abdominal CT scan or ultrasonography.
Surgery. Few would argue that
generalized peritonitis with or without overwhelming intra-abdominal
sepsis, with or without evidence of free perforation, should be
treated surgically. Unresolved obstruction and colovesical fistula
also are indications for surgical treatment. Because most patients with
uncomplicated diverticulitis recover with medical treatment and do not have
recurrences of acute disease, surgery is not recommended routinely. However,
failure to improve after several days of medical treatment or recurrence
after successful treatment are indications for surgery in a patient whose
operative risk is reasonable.
Manual of Gastroenterology 1994 - Gregory Eastwoord & Canan Avunduk
Current Therapy in Adult Medicine 4th Ed, 1997 - Jerome Kassierer & Harry
ACP Library on Disk 2- (c) 1997 - American College of Physicianss