Editors

IlmoKellokumpu

Diverticulitis and Diverticulosis

Before starting conservative treatment of diverticulitis make sure - based on clinical picture and on additional investigations if necessary - that the patient does not have a bowel obstruction or perforation necessitating surgery.
Do not diagnose prolonged or recurring lower abdominal symptoms as diverticulosis before examining the patient thoroughly (knowing that the patient has diverticula must not prevent from investigating the cause of abdominal symptoms)

Pain and tenderness on palpation, usually in left lower quadrant or the abdomen
Mild fever (usually below 38.5°C)
ESR and CRP are often increased. If CRP exceeds 100 mg/l the patient should be hospitalized.
The diagnosis is specified with
- primarily CT scan of the abdomen in the acute phase, or
- colonoscopy one month after the acute episode (to confirm the existence of diverticula and to exclude colorectal cancer, particularly in complicated diverticulitis).

Usually asymptomatic
Symptoms may resemble those of irritable bowel syndrome Functional Bowel Disorders and the Irritable Bowel Syndrome (IBS).
Bleeding from a diverticulum may be a cause of faecal blood originating from the rectum. If the bleeding is profuse, refer the patient to a hospital where the bleeding site is localized by angiography and the bleeding is stopped either by radiological intervention or by surgery.
The diagnosis is based on colonoscopy (video Diverticular Disease of the Colon) showing the diverticula or the diverticular orifices.

Constipation should be treated.
Diet rich in fibre is probably beneficial in the prevention and treatment of diverticulosis irrespective of whether the patient has constipation.

Patients with mild symptoms can be safely treated as outpatients.
If the patient is febrile, has strong abdominal pain, and peritoneal irritation is detected, the patient should be hospitalized and intravenous fluids should be given. Surgical treatment is indicated if the condition of the patient becomes complicated.
As a complication of diverticulitis, a peri-colic or pelvic abscess (Hinchey stages I and II), a perforation and a peritonitis (Hinchey stages III and IV) may develop. In addition, obstruction of the colon or fistula formation (e.g., a colo-vesical fistula) may occur.

Uncomplicated diverticulitis may heal without antimicrobial treatment.
The first diverticulitis should be confirmed by a CT scan.
After the diagnosis has been once confirmed by a CT scan, the subsequent episodes of diverticulitis with mild symptoms can be diagnosed and symptomatically treated within primary care using pain medication on demand, without performing imaging studies.
The patient should be followed up and antimicrobial medication should be started if the symptoms do not ease up within a few days or if they become worse.

Can be used in mild cases.
Can be chosen as line of treatment also in the initial phase, without a trial of non-pharmacological treatment.
Cephalexin 500 mg 3 times daily, doxycycline 150 mg once daily or ciprofloxacin 500 mg twice daily in combination with metronidazole 400 mg 3 times daily for 10 days

Is indicated if there is peritoneal irritation, if plasma CRP concentration is markedly increased or if CT reveals a complicated diverticulitis.
Second generation cephalosporins (e.g. cefuroxime 1.5 g × 3 i.v.) in combination with metronidazole 500 mg × 3 is the drug of choice.
If the diverticulitis is not settled by conservative treatment, a CT scan of the abdomen is warranted to diagnose a potential abscess which usually requires percutaneous drainage to heal.

Even recurrent bouts of uncomplicated diverticulitis can as a rule be treated conservatively.
Indications for surgical treatment include
- complicated diverticulitis (fistulae, strictures)
- recurrent bouts of diverticulitis with exceptionally severe symptoms and recurrent sick leaves.