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Diverticulitis                                              SX  |  DX  |  RX                                                                                    

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 and peritonitis.

SX of Diverticulitis:
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.

Diagnostic studies:

1. CBC: leukocytosis
2. 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.
3. 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.
4. 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).

Treatment of Diverticulitis:

1. Diet restriciton: nothing by mouth; performing nasogastric suction as indicated, and administering intravenous fluids and electrolytes.
2. 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 q8h IV)
   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
3. Percutaneous abscess drainage under ultrasound or computed tomographic (CT) guidance should be considered if an abscess is identified by abdominal CT scan or ultrasonography.
4. 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.

Ref:
Manual of Gastroenterology 1994 - Gregory Eastwoord & Canan Avunduk
Current Therapy in Adult Medicine 4th Ed, 1997 - Jerome Kassierer & Harry Greene II
ACP Library on Disk 2- (c) 1997 - American College of Physicianss