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diverticulitis

Etiology: - microperforation with inflammation of a diverticulum - risk factors - aspirin & NSAIDS increase risk of diverticulitis [4] - red meat intake increases risk of diverticulitis [18] - 18% increase in risk with each daily serving [18] Epidemiology: - more common in women [22] Pathology: - microperforation of diverticula - diverticula become blocked, trap colonic bacteria, & subsequently become inflamed [2] - obstruction at the diverticular neck by fecal matter - mucus accumulation - bacterial overgrowth - inflammation. Clinical manifestations: 1) abdominal pain & tenderness a) may be crampy initially (colic), but becomes constant in nature b) generally left lower quadrant pain c) onset is frequently gradual d) 'acute' abdomen is uncommon 1] secondary to peritonitis 2] abdominal guarding & rebound tenderness 3] may represent frank perforation 4] surgical emergency e) relief with flatus or bowel movment [2] 2) fever > 38 C (may be < 38 C in uncomplicated cases) 3) changes of bowel habits a) constipation (most common) b) diarrhea (less frequently) c) ref [2] suggests diarrhea more common 4) nausea/vomiting a) localized inflammation/edema-induced obstruction b) abscess causing obstruction c) spasm d) sepsis e) electrolyte abnormalities 5) malaise 6) urinary complaints a) dysuria/frequency secondary to adjacent bladder inflammation b) pneumaturia secondary to colovesical fistula 7) hypoactive bowel sounds, ileus 8) occult fecal blood to bright red blood per rectum - may present as recurrent BRBPR without abdominal pain [2] - MKSAP19 states acute diverticulitis does not present with rectal bleeding [2] 9) abdominal mass if significant abscess or inflammation Laboratory: 1) complete blood count (CBC) with differential - leukocytosis with left shift 2) elevated inflammatory markers a) erythrocyte sedimentation rate (ESR) is generally elevated b) elevated serum C-reactive protein c) elevated serum procalcitonin 2) urinalysis for evidence of colovesical fistula a) hematuria b) pyuria Special laboratory: - flexible sigmoidoscopy, colonoscopy a) of limited value, except in cases of complicated left-sided diverticulitis - colorectal cancer can masquerade as left-sided diverticulitis b) avoid in the acute setting - wait minimum of 6-8 weeks after resolution of symptoms c) risk of insufflation-induced intestinal perforation [2] d) colonoscopy 1-2 months after recovery to rule out colon cancer - see Follow-up in Management section Radiology: 1) imaging - unnecessary if clinical features highly suggestive of diverticulitis [2] - helpful with predictive value - failure of medical treatment - development of complications [2] 2) computed tomography (CT) of abdomen & pelvis [25] a) imaging modality of choice - low radiation dose without contrast [3] b) indications: - diagnosis & guidance of therapy [2] - severe pain, high fever, palpable mass c) features - sigmoid diverticula with focal bowel wall thickening - inflammation of the pericolic fat. [2] - diverticular pericolic abscess vs non-diverticular etiology of abdominal pain [2] d) procedure: CT-guided drainage of larger abscesses [2] 3) plain abdominal radiograph a) signs of obstruction - distended bowel loops with abrupt termination - air/fluid interfaces b) signs of perforated viscus (rare) - free air under the diaphragm c) ileus (common) d) extracolonic gas pattern suggestive of pericolic abscess 4) barium enema with water-soluble contrast - poor yield of extracolonic pathology 5) abdominal ultrasound - generally less useful than CT or barium enema Differential diagnosis: 1) intestinal ischemia (ischemic colitis) a) patient generally with diffuse atherosclerotic disease b) abdominal pain & tenderness over affected region c) BRBPR ischemic colitis d) hypotension, use of vasopressor suggests ischmemic colitis [2] 2) colorectal cancer 3) intestinal obstruction 4) appendicitis 5) duodenal ulcer 6) inflammatory bowel disease 7) tubo-ovarian abscess: - generally younger, sexually-active women 8) sigmoid volvulus 9) pancreatitis 10) diverticular bleeding (without diverticulitis) is painless [2] 11) pyelonephritis [25] 12) urolithiasis [25] Complications: 1) fistula to bladder (enterovesical fistula), vagina or skin - enterovesical 2) pericolic abscess: a) if < 2 cm, medical management b) CT-guided drain placement for pericolic abscesses >= 4 cm in diameter & nonresolving pericolic abscess [31] 3) bowel perforation & peritonitis: surgery 4) bowel obstruction: surgery 5) most chronic symptoms likely related to visceral hypersensitivity [28] Management: 1) indications for hospital admission a) evidence of obstruction b) unable to tolerate liquid diet c) significant fever d) leukocytosis (WBC > 12,000/mm3) e) severe abdominal pain & tenderness f) immunosuppression [2] g) failure to improve after 24-36 hours h) uncomplicated diverticulitis may be treated as outpatient even in elderly with comorbidities [16] 2) nasogastric tube (NGT) for decompression if distended 3) pharmacologic agents b) avoid antibiotics in otherwise healthy adults with early diverticulitis [2] b) antibiotic coverage 1] E coli, Bacteroides fragilis, anaerobes 2] 7-10 days of therapy c) mild cases/outpatient [7] 1] ciprofloxacin 500 mg PO BID + metronidazole 500 mg PO BID 2] tetracycline or Bactrim plus metronidazole 3] amoxicillin/clavulanate [7,27] 4] antibiotics do not improve outcomes [29] - antibiotics not routinely required in immunocompetent patients [30] 5] higher risk of C difficile colitis with quinolone vs amoxicillin/clavulanate in elderly [27] d) hospitalized patients - ciprofloxacin 500 mg PO BID plus metronidazole 500 mg PO BID [2] even in ICU patient unless unable to tolerate oral diet (persistent vomiting) - intravenous antibiotics - ceftriaxone + metronidazole - ampicillin + aminoglycoside + metronidazole - ampicillin sulbactam (Unasyn) - ticarcillin clavulanate (Timentin) - piperacillin tazobactam (Zosyn) - Imipenem cilastatin (Primaxin) - transition to oral antibiotics when food is tolerated [2] e) limitations of antibiotics - antibiotics may not improve outcomes [18,29] - antibiotics do not reduce pain, complictions requiring surgery, readmission or length of hospitalization in uncomplicated diverticulitis [24] f) indications for antibiotics in uncomplicated cases [28] - comorbidities - immunosuppression - serum C-reactive protein > 140 mg/L - WBC count > 15,000/uL - presence of fluid collection - long segment of inflammation on imaging [28] 4) intravenous fluids 5) analgesics 6) CT-guided drainage of larger abscesses [2] 7) surgery (colectomy) a) >= 3 acute attacks of diverticulitis [15] b) a single attack - requiring hospitalization in a patient < 40 years of age - evidence of perforation, colonic obstruction, peritonitis, sepsis or inflammatory involvement of the urinary tract - recurrent & persistent symptoms after a diverticulitis episode [17] c) inability to rule out colon carcinoma d) for perforated bowel, surgical resection comparable to peritoneal lavage in complications (26-31%) & overall mortality (12-14%), but less likely to need reoperation & sigmoid colon cancers may be revealed during surgery [10] e) > 50% of elective colectomy surgeries for diverticulitis do not meet guideline criteria [15] f) absolute risks of readmission & emergency surgery are low after nonoperative management of diverticulitis [9] - 5 year risk of readmission = 9% - 5 year risk of emergency surgery = 2% g) elective colectomy does not prevent subsequent emergency surgery [13,25] h) decision for surgery should be individualized [23] - not based solely on number of diverticulitis episodes [28] 8) diet a) nothing by mouth (NPO) in hospitalized patients - resume diet slowly after symptoms have improved [2] b) liquid diet for outpatients c) low-residue diet with stool softener after resolution of acute attack (prevention of recurrence) d) gradual increase in dietary fiber to 25-35 gm/day e) fiber from fruits & cereals, but not vegetables, associated with decreased risk for diverticulitis in women [22] f) high-quality diet (high-fiber, vegetarian) 9) other preventive measures a) regular physical activity b) normal body-mass index c) smoking cessation d) avoid NSAIDs (except low-dose aspirin) e) no medications are proven to lower risk for recurrence [28] Follow-up: 1) colonoscopy 1-2 months after recovery [2] or persistent symptoms [28] a) evaluate extent of disease b) evidence of malignancy (colon cancer) [2] 1] incidence of colorectal cancer in patients with uncomplicated diverticulitis is very low (1.1%) [8] 2] colonoscopy may be unnecessary after radiologically proven uncomplicated diverticulitis [8] c) evidence of stricture 2) barium enema 3) abdominal CT for persistent symptoms 4) recurrent attacks are common [14] - recurrence after 1st episode: 8% at year, 17% at 5 years, 22% at 10 years - recurrence after 2nd episode: 19% at year, 44% at 5 years, 55% at 10 years

General

diverticulosis gastrointestinal infection bacterial infection

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 350-52
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Tack D, Bohy P, Perlot I, De Maertelaer V, Alkeilani O, Sourtzis S, Gevenois PA. Suspected acute colon diverticulitis: imaging with low-dose unenhanced multi-detector row CT. Radiology. 2005 Oct;237(1):189-96. Epub 2005 Aug 26. PMID: 16126929
  4. Strate LL et al. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011 May; 140:1427 PMID: 21320500
  5. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15;357(20):2057-66. PMID: 18003962
  6. Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am. 2009 Sep;38(3):513-25 PMID: 19699411
  7. Biondo S et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: A prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2014 Jan; 259:38 PMID: 23732265
  8. Sharma PV et al. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014 Feb; 259:263 http://journals.lww.com/annalsofsurgery/pages/articleviewer.aspx?year=2014&issue=02000&article=00011&type=abstract
  9. Li D et al. Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: A population-based analysis. Ann Surg 2014 Sep; 260:423 PMID: 25115418
  10. Schultz JK, Yaqub S, Wallon C et al Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis. The SCANDIV Randomized Clinical Trial. JAMA. 2015;314(13):1364-1375. PMID: 26441181 - Strong SA, Soper NJ Minimally Invasive Approaches to Rectal Cancer and Diverticulitis. Does Less Mean More? JAMA. 2015;314(13):1343-1345 PMID: 26441178
  11. Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis. 2012 Jan;14(1):e1-e11. PMID: 21848896
  12. Wilkins T, Embry K, George R Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20. PMID: 23668524
  13. Simianu VV et al. The impact of elective colon resection on rates of emergency surgery for diverticulitis. Ann Surg 2016 Jan; 263:123. PMID: 26111203
  14. Bharucha AE, Parthasarathy G, Ditah I et al. Temporal trends in the incidence and natural history of diverticulitis: A population-based study. Am J Gastroenterol 2015 Nov; 110:1589. PMID: 26416187 http://www.nature.com/ajg/journal/v110/n11/full/ajg2015302a.html
  15. Simianu VV et al Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions. JAMA Surg. Published online February 10, 2016 PMID: 26864286 http://archsurg.jamanetwork.com/article.aspx?articleid=2486922 - Fleshman J Improving Treatment of Uncomplicated Diverticulitis. The Old Appendicitis. JAMA Surg. Published online February 10, 2016 PMID: 26865193 http://archsurg.jamanetwork.com/article.aspx?articleid=2486916
  16. Rodriguez-Cerrillo M, Poza-Montoro A, Fernandez-Diaz E et al Treatment of elderly patients with uncomplicated diverticulitis, even with comorbidity, at home. Eur J Intern Med. 2013 Jul;24(5):430-2. PMID: 23623263
  17. van de Wall BJ, Stam MA, Draaisma WA et al Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open- label, multicentre, randomised controlled trial. Lancet Gastroenterology & Hepatology. Oct 19, 2016 Not indexed in PubMed http://www.thelancet.com/journals/langas/article/PIIS2468-1253(16)30109-1/fulltext - Schultz JK When is elective resection after acute diverticulitis reasonable? Lancet Gastroenterology & Hepatology. Oct 19, 2016 Not indexed in PubMed http://www.thelancet.com/journals/langas/article/PIIS2468-1253(16)30112-1/fulltext
  18. Cao Y, Strate LL, Keeley BR et al Meat intake and risk of diverticulitis among men. Gut. Jan 9, 2017 PMID: 28069830 http://gut.bmj.com/content/early/2017/01/03/gutjnl-2016-313082
  19. van Dijk ST, Daniels L, Unlu C et al. Long-term effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol. 2018 Jul;113(7):1045-1052. PMID: 29700480 - Peery AF. It's actually a little complicated: Antibiotics for uncomplicated diverticulitis. Am J Gastroenterol 2018 Jul; 113:949. PMID: 29925917
  20. Young-Fadok TM Diverticulitis. N Engl J Med 2018; 379:1635-1642. Oct 25, 2018 PMID: 30354951 https://www.nejm.org/doi/full/10.1056/NEJMcp1800468 - Rothaus C Diverticulitis. NEJM Resident 360. Oct.24, 2018 https://resident360.nejm.org/content_items/diverticulitis-2
  21. Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute Technical Review on the Management of Acute Diverticulitis. Gastroenterology. 2015 Dec;149(7):1950-1976.e12. PMID: 26453776 - Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology. 2019;156(5):1282-1298.e1 PMID: 30660732 PMCID: PMC6716971 Free PMC article https://www.gastrojournal.org/article/S0016-5085(19)30046-0/fulltext
  22. Ma W, Nguyen L, Song M et al. Intake of dietary fiber, fruits, and vegetables and risk of diverticulitis. Am J Gastroenterol 2019 Aug 7; PMID: 31397679 https://insights.ovid.com/crossref?an=00000434-900000000-99583
  23. Strassle PD, Kinlaw AC, Chaumont N et al. Rates of elective colectomy for diverticulitis continued to increase after 2006 guideline change. Gastroenterology 2019 Sep 6; PMID: 31499038 https://www.gastrojournal.org/article/S0016-5085(19)41303-6/pdf
  24. Chabok A, Pahlman L, Hjern F et al Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9 PMID: 22290281 Clinical Trial. - Daniels L, Unlu C, de Korte N et al Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61 PMID: 27686365 Clinical Trial. - Jaung R, Nisbet S, Gosselink MP et al. Antibiotics do not reduce length of hospital stay for uncomplicated Diverticulitis in a pragmatic double-blind randomized trial. Clin Gastroenterol Hepatol 2020 Mar 30 PMID: 32240832 https://www.cghjournal.org/article/S1542-3565(20)30426-2/pdf
  25. von Strauss und Torney M, Moffa G, Kaech M et al. Risk of emergency surgery or death after initial nonoperative management of complicated diverticulitis in Scotland and Switzerland. JAMA Surg 2020 May 13 PMID: 32401298 Free PMC article https://jamanetwork.com/journals/jamasurgery/fullarticle/2765846
  26. Weinrich JM, Bannas P, Avanesov M et al. MDCT in the setting of suspected colonic diverticulitis: Prevalence and diagnostic yield for diverticulitis and alternative diagnoses. AJR Am J Roentgenol 2020 Jul; 215:39-49. PMID: 32319796 https://www.ajronline.org/doi/10.2214/AJR.19.21852
  27. Gaber CE, Kinlaw AC, Edwards JK et al Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis. Two Nationwide Cohort Studies. Ann Intern Med. 2021. Feb 23 PMID: 33617725 https://www.acpjournals.org/doi/10.7326/M20-6315
  28. Peery AF et al. AGA clinical practice update on medical management of colonic diverticulitis: Expert review. Gastroenterology 2021 Feb; 160:906. PMID: 33279517 PMCID: PMC787833 https://www.gastrojournal.org/article/S0016-5085(20)35512-8/fulltext
  29. Mora-Lopez L, Ruiz-Edo N, Estrada-Ferrer O et al. Efficacy and safety of nonantibiotic outpatient treatment in mild acute diverticulitis (DINAMO-study): A multicentre, randomised, open-label, noninferiority trial. Ann Surg 2021 Nov; 274:e435 PMID: 34183510
  30. Qaseem A et al. Colonoscopy for diagnostic evaluation and interventions to prevent recurrence after acute left-sided colonic diverticulitis: A clinical guideline from the American College of Physicians. Ann Intern Med 2022 Jan 18; [e-pub]. PMID: 35038270 https://www.acpjournals.org/doi/10.7326/M21-2711 - Balk EM et al. Diagnostic imaging and medical management of acute left-sided colonic diverticulitis: A systematic review. Ann Intern Med 2022 Jan 18; [e-pub] PMID: 35038271 https://www.acpjournals.org/doi/10.7326/M21-1645
  31. NEJM Knowlege+ Question of the Week. Dec 6, 2022 https://knowledgeplus.nejm.org/question-of-week/439/
  32. Stollman N, Smalley W, Hirano I. AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149:1944-1999. PMID: 26453777
  33. Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, et al Clinical Guidelines Committee of the American College of Physicians*. Diagnosis and management of acute left-sided colonic diverticulitis: A clinical guideline from the American College of Physicians. Ann Intern Med. 2022;175:399-415. PMID: 35038273
  34. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diverticular Disease https://www.niddk.nih.gov/health-information/digestive-diseases/diverticulosis-diverticulitis