Acute Diverticulitis


Article Author:
Catherine Linzay


Article Editor:
Sudha Pandit


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/18/2018 5:25:12 PM

Introduction

Acute diverticulitis is inflammation due to micro-perforation of a diverticulum. The diverticulum is a sac-like protrusion of the colon wall. Diverticulitis can present in about 10% to 25% of patients with diverticulosis. Diverticulitis can be simple or uncomplicated and complicated. Uncomplicated diverticulitis is without any associated complications. Complicated diverticulitis is associated with the formation of abscess, fistula, bowel obstruction, or frank perforation. Diverticulitis has conventionally been known and treated as a primarily surgical illness, but this has transitioned to be a medically managed entity even in its most acute phase.[1][2][3]

Etiology

Risk factors that increase the chances of developing diverticulitis are the same as those related to diverticulosis. Diet appears to play a significant role. Low fiber, high fat, and red meat diets may increase the risk for development of diverticulosis and possible diverticulitis. Obesity and smoking are known to increase the potential for both diverticulitis and diverticular bleeding. Finally, exposure to some drugs including nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and opiates are associated with diverticulitis. Conversely, exposure to statin drugs may decrease the incidence of symptomatic diverticulitis.  Despite a common popular belief, nuts, seeds, and popcorn are not associated with increased risk of diverticulosis, diverticulitis, or diverticular bleeding.[4][5]

Epidemiology

Diverticulosis is present in approximately 60% of people older than 60 years. Diverticulitis occurs in about 10% to 25% of patients with diverticulosis. According to the Nationwide Inpatient Sample (NIS), the largest, all-payer inpatient care database in the United States revealed that there was 26% increase in hospitalizations for acute diverticulitis and a 38% increase in elective operations from 1998 through 2005. It further shows that young patients (18 to 44 years) are more likely to be admitted to the hospital than older patients (45 to 74 years). This trend is likely due to prompt diagnosis and improvement in diagnostic testing modalities. Western nations are overwhelmingly likely to have left-sided diverticulosis, whereas those of Asian descent are likely to have the right-sided disease. Across the world, the mean age for admission for acute diverticulitis is 63 years old. Though the disease was initially noted to be more prevalent in males, more recent data shows that the distribution of diverticulitis is equal in both males and females. Diverticulitis more commonly occurs in men younger than the age of 50 and women 50 to 70 years old. Diverticulitis occurring in patients over the age of 70 are more likely to be female.[6]

Pathophysiology

Diverticulitis is the result of microscopic and macroscopic perforations of the diverticular wall. Previously, practitioners thought that obstruction of colonic diverticulum with fecaliths led to increased pressure within the diverticulum and subsequent perforation. They now theorized that increased luminal pressure is due to food particles that lead to erosion of the diverticular wall. This causes focal inflammation and necrosis of the region, causing perforation. Surrounding mesenteric fat may easily contain micro-perforations. This can result in local abscess formation, fistulization of adjacent organs, or intestinal obstruction. Ultimately, frank bowel wall perforations can lead to peritonitis and death without rapid diagnosis and treatment.[7]

History and Physical

Clinical manifestation of acute diverticulitis varies depending on the severity of the disease. Patients with uncomplicated diverticulitis typically present with left lower quadrant abdominal pain, reflecting that propensity of left-sided disease in Western nations. However, patients of Asian descent present with predominantly right-sided abdominal pain. The pain can be constant or intermittent. Change in bowel habits, either diarrhea (35%) or constipation (50%), can be associated with abdominal pain. Patients may also experience nausea and vomiting, possibly secondary to bowel obstruction. Fever is not uncommon in patients with abscesses and perforation. Dysuria, frequency, and urgency can occur in patients when the inflamed portion of the bowel comes into direct contact with the bladder wall, which is called as sympathetic cystitis.

On physical examination, tenderness to palpation over the area of inflammation is almost always present due to irritation of the peritoneum. A mass may be felt in approximately 20% of patients if an abscess is present. Bowel sounds are usually hypoactive but can be normoactive. Patients can present with peritoneal signs (rigidity, guarding, rebound tenderness) with bowel wall perforation. On the other hand, fever is almost always present, but hypotension and shock are uncommon. 

Evaluation

Diagnosis of acute diverticulitis can be made clinically based on history and physical examination alone. However, clinical diagnosis can be inaccurate in 24% to 68% of cases. Hence, laboratory and radiological tests play an important role in the accurate diagnosis of acute diverticulitis. Laboratory tests may show leukocytosis and elevation of acute phase reactants such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The radiological test of choice for acute diverticulitis is CT of the abdomen and pelvis, preferably with water-soluble oral or rectal (if significant nausea and vomiting) contrast and intravenous contrast provided there be no contraindications. The sensitivity, specificity, and negative predictive value of a CT scan have been reported as greater than 97%. Typical findings of acute diverticulitis in CT scans include bowel wall thickening, pericolic fat stranding, pericolic fluid, and small abscesses confined to the colonic wall as well as contrast extravasation, indicating intramural sinus and fistula formation.[8]

Abdominal ultrasound can accurately diagnose acute diverticulitis, with comparative sensitivity (84% to 94%) and specificity (80% to 93%) as of CT. However, ultrasound (US) results are highly operator dependent, and use is limited despite encouraging data, lower cost, and easy availability. MRI is another possible diagnostic modality. Due to cost and no direct comparison of sensitivity or specificity, CT is usually preferred. Radiographs of the abdomen will probably only show nonspecific abnormalities such as bowel gas; however, if the patient has an intestinal obstruction, air-fluid levels can be present.

Endoscopy should be avoided in suspected acute diverticulitis due to an increased risk of perforation. It is recommended that a colonoscopy is performed approximately six to eight weeks after symptoms have resolved to rule out malignancy, inflammatory bowel disease, or possibly colitis if the patient has not had a recent colonoscopy.

Treatment / Management

Upon clinical presentation, acute diverticulitis can be managed with either outpatient or inpatient care. According to American Society of Colon and Rectal Surgeons, a patient who cannot tolerate oral intake, is excessively vomiting, shows signs of peritonitis, is immunocompromised, or at an advanced age should be hospitalized. In the absence of these conditions, and if appropriate prompt follow-up can be established, acute diverticulitis can be managed on an outpatient basis. It is reported that success rate of outpatient management is about 94% to 97%. The standard of outpatient care includes bowel rest, increase fluid intake, and oral antibiotic therapy (single or multiple drug regimen) that covers gram-negative rods and anaerobic bacteria. The most common regimen used in the United States consists of quinolones (ciprofloxacin) or sulfa drugs (trimethoprim/sulfamethoxazole) in combination with metronidazole  (or clindamycin, if the patient is intolerant to metronidazole) or single agent amoxicillin-clavulanate for 7 to 10 days.[8][3][9]

Inpatient management of diverticulitis requires intravenous antibiotics, intravenous fluids, and pain management. Again, antibiotics should cover gram-negative rods and anaerobes and be given for three to 5 days before switching to oral antibiotics for a ten to 14-day course. Bowel rest is preferred in patients requiring inpatient admission. Typically, defervescence and improvement in leukocytosis should be observed for two to four days of hospitalization, if not an alternative diagnosis or complications should be suspected. Prompt surgical evaluation should be considered.

About 15% patients with acute diverticulitis develop an abscess, specifically pericolonic and intra-mesenteric. Clinically, abscess formation should be suspected if fever and leukocytosis do not subside despite adequate intravenous (IV) antibiotics. On physical exam, a tender abdomen and tender mass suggest possible abscess formation. Abscesses that are less than 2 cm to 3 cm can be treated conservatively with IV antibiotics. Large abscesses should be drained percutaneously with CT guidance.

Fistula formation is another complication of acute diverticulitis. It is reported that less than 5% develops fistula; however, it has been found in about 20% of patients who undergo surgery for diverticulitis. The most common fistula is colovesicular fistula which occurs in about 65% of cases. Fecaluria is pathognomonic for colovesicular fistula. Surgical repair of the fistula with primary anastomosis is the treatment of choice. Colovaginal, coloenteric, colouterine, colourethral, and colocutaneous are other possible fistulae seen in acute complicated diverticulitis.

Partial bowel obstruction or pseudo-obstruction due to colonic ileus can occur as well, which can be managed conservatively. Complete bowel obstruction is rare in acute diverticulitis. Free perforation, if it occurs, should be managed surgically.

Prognosis

The prognosis of patients with diverticulitis depends on age at presentation, the presence of comorbidity and severity of the disease. In general, younger people tend to have a higher morbidity as they never suspect they have the disorder and often present late. In addition, patients who are immunocompromised tend to have high morbidity and mortality.[10]

Complications

  • Pelvic abscess
  • Intestinal perforation
  • Bowel fistula
  • Peritonitis
  • Bowel obstruction
  • Sepsis
  • Bleeding per rectum

Postoperative and Rehabilitation Care

After recovering from diverticulitis, the patient must be examined to rule out a malignancy. Options for investigation of the colon include colonoscopy, CT scan or a barium enema.

The patient should start a high-fiber diet, drink ample water, maintain a healthy weight and exercise.

Deterrence and Patient Education

A high-fiber diet can prevent diverticulosis.

Pearls and Other Issues

As previously stated, approximately 15% of patients with acute diverticulitis develop complications. Twenty percent to 50% of patients develop recurrent episodes of diverticulitis. Having multiple episodes does not appear to increase the risk for complications directly. It may increase the risk of fibrosis, leading to stricture formation and subsequent obstruction. Some patients, approximately 20%, will experience chronic abdominal pain due to either irritable bowel syndrome or chronic low-grade diverticulitis. These patients may be referred for elective colectomy for symptom control. Elective operations for diverticulitis have increased by approximately 30% since 1998.

The mortality rate in uncomplicated diverticulitis is negligible with appropriate conservative therapy. Complicated diverticulitis requiring surgery may lead to death in approximately 5% of patients. Perforation of the bowel with resulting peritonitis increases the risk of death to 20%.

Enhancing Healthcare Team Outcomes

Acute diverticulitis has enormous morbidity and while there are no universal guidelines, expert opinion recommends an interprofessional approach for diagnosis and management. The disorder needs to be staged radiologically. In addition, the patient needs a dietary consult regarding a high-fiber diet. Nurses need to assist in educating the patient on following dietary restrictions. An infectious disease consultant and a gastroenterologist need to determine the duration of antibiotic therapy and a general surgeon is necessary to develop a protocol for management of any pelvic abscess. Finally, a general or colorectal surgery should determine the proximal levels of colon resection but the amount of clear proximal margin needed remains unknown. Because the risk of colon cancer in patients with acute diverticulitis is slightly increased, a screening program has to be established.[11][12] [13] (Level III)

Outcomes

Many cases studies reveal that the majority of patients treated for acute diverticulitis do not have a recurrence after initial medical treatment. However, in patients with recurrence, surgical excision of the diseased bowel is recommended, especially in patients over the age of 50. (Level V) Finally, the decision to perform laparoscopic or open surgery for managing acute diverticulitis remains debatable. One study showed no difference in postoperative morbidity between the two. [2][14](Level III) Randomized clinical studies are needed to determine which surgery and what type of surgery is ideal for patients with acute diverticulitis.


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Acute Diverticulitis - Questions

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What is the best diagnostic study to order in the case of a elderly male with history of hypertension and depression on enalapril and who presents with complains of abdominal pain for 3 days and is found on exam to have a BP of 155/82, pulse 105, temperature of 101.5°F (38.6°C), respiration 15, abdominal rebound tenderness in the left lower quadrant and a white blood cell count of 30,000?



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What is the most accurate imaging study for acute diverticulitis?



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A 75-year-old man is admitted to your service because of diverticulitis. He is febrile to 103 degrees. His blood pressure falls to 79/60 with a pulse of 130 beats per minute. He seems restless. Of the following, what is the most important step in treatment?



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A 75-year-old man is admitted for abdominal pain. He is febrile to 103 F. His blood pressure falls to 90/60 mmHg with a pulse of 130 beats/min. He seems restless and agitated. A urinalysis shows many bacteria and WBCs. He also has thick, brown discharge in his Foley catheter. CT abdomen confirms active diverticulitis with a colovesical fistula. What is the next step in management?



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A 75-year-old man is admitted to your service because of diverticulitis. He is febrile to 103 degrees. His blood pressure falls to 90/60 with a pulse of 130. He seems restless and agitated. What is the next step in treatment prior to surgery?



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A 75-year-old man is admitted to your service because of left lower quadrant pain. He is febrile to 103 degrees. His blood pressure falls to 90/60 with a pulse of 130. He seems restless. You suspect acute diverticulitis. What is the best confirmatory test?



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A 65-year-old male with a history of hypertension and depression on enalapril and citalopram presents with abdominal pain for 4 days. Exam reveals a blood pressure of 156/85 mmHg, pulse 115 bpm, temperature of 101.5 F (38.6 C), respirations of 16, abdominal rebound tenderness in the left lower quadrant, and a white blood cell count of 34,000. What is the next best step?



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A 70-year-old male is admitted with left lower abdominal colicky pain that started 3 days ago. The patient has had 3 prior episodes all of which resolved within a couple of days. He has been having alternating constipation and diarrhea for 6 months. He has had nausea without vomiting. He has not had any stools or gas per rectum for 24 hours. Vital signs are temperature 101.4 degrees F, pulse 95 and regular, BP 155/95 mm Hg, and respirations 20. Which of the following is the least urgent information at this time?



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A 65-year-old woman is admitted for recurrent diverticulitis. She has had a 4-day history of fevers and abdominal pain. She reports bubbles in her urine. CT scan shows colonic wall thickening and pericolic fat stranding. Select the most appropriate management.



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An adult patient presents with left lower quadrant pain, diarrhea and guarding without rebound. The most appropriate next step would be:



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Which of the following is the least appropriate antibiotic regimen for outpatient treatment of uncomplicated diverticulitis?



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A 70-year-old male is admitted with a three-day history of left lower colicky abdominal pain. The patient has had three prior episodes all of which resolved within a couple of days. He has been having alternating constipation and diarrhea for six months. He has had nausea without vomiting. He has not had any stools or gas per rectum for 24 hours. Vital signs are temperature 101.4 F, pulse 95 bpm, and regular, blood pressure 155/95 mmHg, and respirations 20/minute. Which of the following is the least urgent information at this time?



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Which of the following is associated with acute diverticulitis? Select all that apply.



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A 66-year-old male presents to the emergency department with a one-day history of left lower quadrant pain, nausea, vomiting, and fever. His temperature is measured to be 39 C, pulse 98/min and blood pressure 102/74 mmHg. Blood tests showed an elevated WBC count. CT scan shows sigmoid wall thickening and peri-sigmoid fat stranding. Which of the following is a risk factor for this patients condition?

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Attributed To: Image courtesy S Bhimji MD



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A 24-year-old male enrolls as a volunteer in a research study about the effects of stress on the colon. He has no past medical history and takes no medications. His weight is 70kg and height is 176cm. He agrees to have a colonoscopy with biopsy of the mucosa. The colonoscopy finding is shown in the image. He was advised to go visit his clinician to further evaluate this abnormality. Which of the following tests should be done for this patient?

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    Contributed by Sultan Mahmood, MD.
Attributed To: Contributed by Sultan Mahmood, MD.



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A 58-year-old male presents to the ER complaining of left lower abdominal pain and fever. He has a past medical history of hypertension, osteoarthritis, and COPD. His mediations include hydrochlorothiazide, ibuprofen, and inhaled salmeterol and albuterol. BP: 135/83, HR: 79, RR: 19, O2: 97%, T: 38.3 C. Blood tests revealed an elevated WBC count. CT scan showed sigmoid colon thickening with fat standing. He was given oral ciprofloxacin and metronidazole and instructed to take them for 10 days and then discharged from the hospital. 3 days later, he returns to the ER stating that his symptoms have not improved. BP: 129/80, HR: 85, RR: 20, O2: 96%, T: 39 C. CT scan shows a fluid containing mass in the sigmoid colon. Which of the following is the most appropriate next step in the management of this patient?



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A 65-year-old man presents to the emergency department with worsening left lower quadrant (LLQ) pain for the last 2 days. The pain is continuous, stabbing, and is not relieved by over the counter medications. On physical examination, his LLQ is tender with localized guarding and rebound tenderness. His vitals show a temperature of 40 F, a pulse of 94/min, blood pressure of 142/94 mmHg, and a respiratory rate of 18/min. Which of the following is the most appropriate next step in diagnosis?



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A 65-year-old female with a history of diverticulosis was admitted with the complaint of severe pain in the abdomen. The pain is continuous, crampy, and is not relieved by over the counter medications. On physical examination, the left lower quadrant is tender with mild guarding. Her vitals include a temperature of 39 C, blood pressure of 130/80 mm Hg, respiratory rate of 18/min, and a pulse rate of 83/min. Her WBC count is found to be 17 mm3. A CT scan of the abdomen and pelvis is ordered which reveals diffuse sigmoid diverticulitis with a 6 cm diverticular abscess between the sigmoid and the abdominal wall. She has previously had three episodes of acute diverticulitis of the same intensity in the past 5 years. Which of the following is the most appropriate next step in the management of this patient?



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Acute Diverticulitis - References

References

Maraj B,Wray CM, Antibiotic Discretion in the Treatment of Acute Uncomplicated Diverticulitis: A Teachable Moment. JAMA internal medicine. 2018 Jul 30     [PubMed]
Lanas A,Abad-Baroja D,Lanas-Gimeno A, Progress and challenges in the management of diverticular disease: which treatment? Therapeutic advances in gastroenterology. 2018     [PubMed]
Ahmed AM,Moahammed AT,Mattar OM,Mohamed EM,Faraag EA,AlSafadi AM,Hirayama K,Huy NT, Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2018 Jul 19     [PubMed]
El-Sayed C,Radley S,Mytton J,Evison F,Ward ST, Risk of Recurrent Disease and Surgery Following an Admission for Acute Diverticulitis. Diseases of the colon and rectum. 2018 Mar     [PubMed]
Roig JV,Sánchez-Guillén L,García-Armengol JJ, Acute diverticulitis and surgical treatment. Minerva chirurgica. 2018 Apr     [PubMed]
Severi C,Carabotti M,Cicenia A,Pallotta L,Annibale B, Recent advances in understanding and managing diverticulitis. F1000Research. 2018     [PubMed]
Schieffer KM,Kline BP,Yochum GS,Koltun WA, Pathophysiology of diverticular disease. Expert review of gastroenterology     [PubMed]
Naves AA,D'Ippolito G,Souza LRMF,Borges SP,Fernandes GM, What radiologists should know about tomographic evaluation of acute diverticulitis of the colon. Radiologia brasileira. 2017 Mar-Apr     [PubMed]
Emile SH,Elfeki H,Sakr A,Shalaby M, Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis, and meta-regression of predictors of treatment failure. Techniques in coloproctology. 2018 Jul     [PubMed]
van Dijk ST,Daniels L,Nio CY,Somers I,van Geloven AAW,Boermeester MA, Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis. International journal of colorectal disease. 2017 Dec     [PubMed]
Seoane Urgorri A,Zaffalon D,Pera Román M,Batlle García M,Riu Pons F,Dedeu Cusco JM,Pantaleón Sánchez M,Bessa Caserras X,Barranco Priego L,Álvarez-González MA, Routine lower gastrointestinal endoscopy for radiographically confirmed acute diverticulitis. In whom and when is it indicated? Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2018 Jun 14     [PubMed]
Shah SD,Cifu AS, Management of Acute Diverticulitis. JAMA. 2017 Jul 18     [PubMed]
Meyer J,Orci LA,Combescure C,Balaphas A,Morel P,Buchs NC,Ris F, Risk of Colorectal Cancer in Patients with Acute Diverticulitis: a Systematic Review and Meta-Analysis of Observational Studies. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2018 Jul 26     [PubMed]
Theodoropoulos D, Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy. Clinics in colon and rectal surgery. 2018 Jul     [PubMed]

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