Author:

Joseph S.Palter

Signs and Symptoms

Essential Workup

• CBC
• UA
• Blood cultures and lactate:
  • If showing signs of sepsis
• CT of abdomen/pelvis:
  • Preferred diagnostic modality
  • 97% sensitive and 99% specific for diverticulitis with PO and IV contrast
  • Ability to diagnose nondiverticular causes of abdominal pain
  • Gastrografin contrast is preferred (water soluble); avoid barium contrast, especially when concerned for possible perforation

Diagnostic Tests & Interpretation

Differential Diagnosis

• Colon carcinoma with perforation
• Ischemic colitis
• Bacterial colitis
• Appendicitis:
  • Left-sided pain if peritonitis from ruptured appendix
  • Right-sided diverticular pain with cecal diverticulum (rare) or redundant sigmoid colon
• Inflammatory bowel disease
• Mesenteric ischemia
• Bowel obstruction
• Irritable bowel syndrome
• Ruptured or torsed ovarian cyst
• Pancreatic disease
• Pelvic inflammatory disease
• Peptic ulcer disease
• Renal colic

Prehospital

• Avoid opiates in abdominal pain when underlying cause is uncertain
• Establish intravenous access
• Consider Intravenous crystalloid fluids

Initial Stabilization/Therapy

• Fluid resuscitation with 0.9% normal saline
• Bowel rest:
  • NPO or clear liquid diet
  • Nasogastric tube (NG) tube if persistent vomiting or bowel obstruction suspected

ED Treatment/Procedures

• Recurrent uncomplicated/mild diverticulitis:
  • Stable patients who present with similar symptoms to prior episodes of diverticulitis need limited evaluation
  • Conservative medical therapy with broad spectrum oral antibiotics (see below)
  • Close follow-up to assess for symptoms resolution
• New uncomplicated/mild diverticulitis or unclear diagnosis:
  • Confirm diagnosis with imaging (CT modality of choice in emergency settings)
  • Broad spectrum antibiotics (see below)
  • 90% success rate with conservative therapy
  • Antibiotics may not impact symptom resolution, but may decrease recurrence and future complications
  • Confirmed cases of new diverticulitis should be referred to GI for consideration of postresolution colonoscopy
• Complicated diverticulitis:
  • Broad-spectrum antibiotics
  • Hospital admission
  • Surgical consultation (see below):
    • CT guide percutaneous drainage of abscess
    • Surgical procedure to treat infection and complications
• Analgesia:
  • Anticholinergics (dicyclomine):
    • Reduces colonic spasm
    • Does not mask underlying pathology
  • Opiates for more aggressive pain management (theoretically increase intraluminal pressure, leading to perforation):
    • Caution if hemodynamically unstable
• Surgical interventions:
  • Nonperforated diverticulitis with abscess:
    • CT- or US-guided percutaneous abscess drainage often successful and limits complications and needs for additional surgery
    • Microabscess typically treated with conservative therapy alone
  • Perforated diverticulitis with peritonitis:
    • Requires emergent surgery
    • 2-stage procedure with resection of diseased segment of colon and proximal colostomy followed later with reanastomosis
  • Elective surgery:
    • Indicated for multiple recurrent attacks (>2) without generalized peritonitis (controversial); fistula formation; intractable pain; unresolved obstruction; failure of medical therapy; single serious attack in patient <50 yr of age (controversial)
    • 1-stage procedure following resolution of inflammation from medical therapy
    • Nonoperative management may be considered for complicated diverticulitis
• Outpatient therapy:
  • Clear liquids with follow-up in 2-3 d
  • When acute condition has resolved:
    • High-fiber, low-fat diet to decrease recurrence of attacks

Medication

Mild disease outpatient medication regimens (treat 7-14 d):

• Metronidazole: 500 mg PO q8h PLUSLevofloxacin: 750 mg PO daily ORCiprofloxacin: 500 mg PO q12h ORTrimethoprim/sulfamethoxazole DS: 1 tab PO q12h
• Amoxicillin/clavulanate: 500/125 mg PO q8h or 875/125 mg PO q12h
• Moxifloxacin: 400 mg PO daily

Moderate disease inpatient medication regimens:

• Metronidazole: 500 mg IV q8h PLUSCeftriaxone: 1 g IV daily ORCiprofloxacin: 400 mg IV q12h ORLevofloxacin: 750 mg IV daily ORAztreonam: 2 g IV q8h
• Ertapenem: 1 g IV daily
• Piperacillin-tazobactam: 4.5 g IV q8h
• Moxifloxacin: 400 mg IV q12h

Severe/complicated disease inpatient medication regimens:

• Imipenem: 500 mg IV q6h
• Meropenem: 1 g IV q8h
• Piperacillin-tazobactam: 4.5 mg IV q8h
• Ampicillin: 2 g IV q8h PLUSMetronidazole: 500 mg IV q8h PLUSCiprofloxacin: 400 mg IV q12h ORLevofloxacin: 750 mg IV daily

Outpatient prevention medications:

• Fiber: Goal to reduce intraluminal pressure
• Dicyclomine: Goal to reduce intraluminal pressure, reduce pain
• Rifaximin: Goal to reduce colonic stasis
• Mesalamine: Goal to reduce colonic inflammation that might mimic IBD
• Probiotics: Goal to restore normal colonic bacterial flora and reduce pathogenic inflammation

Disposition

Follow-up Recommendations

• Clear liquids
• Clinical improvement should be seen in 3 d, after which diet can be advanced
• Advise patients to call for increasing pain, fever, or inability to tolerate PO
• Colonoscopy (or contrast enema x-ray with flexible sigmoidoscopy) should be obtained after resolution of initial episode
• Patients do NOT need to avoid seeds and nuts

• EliseiW, TursiA. Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis . Ann Gastroenterol. 2016;29(1):24-32.
• FeuersteinJD, FalcukKR. Diverticulosis and diverticulitis . Mayo Clin Proc. 2016;91(8):1094-1104.
• GrahamA. Diverticulitis. In: TintinalliJE, StapczynskiJ, MaO, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed.New York: McGraw-Hill; 2016.
• OnurMR, AkpinarE, KaraosmanogluAD, et al. Diverticulitis: A comprehensive review with usual and unusual complications . Insights Imaging. 2017;8(1):19-27.
• ShahSD, CifuAS. Management of acute diverticulitis . JAMA. 2017;318(3):291-292.
• StrateLL, PeeryAF, NeumannI. American gastroenterological association technical review on management of acute diverticulitis . Gastroenterology. 2015;149(7):1950-1976.
• ThompsonAE. Diverticulosis and diverticulitis . JAMA. 2016;316(10):1124.

See Also (Topic, Algorithm, Electronic Media Element)

Diverticulosis

ICD9

• 562.11 Diverticulitis of colon (without mention of hemorrhage)

• 562.13 Diverticulitis of colon with hemorrhage

ICD10

• K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding

• K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding

• K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding

• K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding

• K57.2 Diverticulitis of large intestine with perforation and abscess

• K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding

• K57.80 Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding

• K57.81 Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding

• K57.8 Diverticulitis of intestine, part unspecified, with perforation and abscess

SNOMED

• 307496006 Diverticulitis (disorder)

• 4494009 Diverticulitis of large intestine

• 235774002 Colonic diverticular abscess (disorder)

• 76953007 Diverticulitis of colon with perforation (disorder)

• 430347001 Diverticulitis of cecum (disorder)

• 430877000 Diverticulitis of rectum (disorder)