Diverticulitis

• • Results from perforation and/or infection of colonic diverticulum

  • Most common in sigmoid colon

  • Becomes clinically significant when infection spreads through wall of colon, into pericolic tissue

  • May lead to intra-abdominal abscess, peritonitis

  • Believed to result from increased intraluminal pressure

  • Cecal diverticulitis may resemble appendicitis clinically

  • May be complicated by colonic fistulae (colovesical, coloenteric)

  • Involvement of the entire colon in up to 10%

  • Noncomplicated: Localized to colon, pericolic tissue

  • Complicated: Abscess, fistula, obstruction, peritonitis

Epidemiology

• • In western countries, diverticula develops in about 50% of persons (10% by age 40; 65% by age 80)

  • Dietary factors may contribute to formation of diverticula (low fiber)

  • Natural history of patients with diverticula: 10-25% become symptomatic

Symptoms and Signs

• • May present with localized abdominal pain

  • Constipation or increased frequency of defecation

  • Dysuria with inflammatory process involving bladder

  • Nausea, vomiting

  • Fever

  • Abdominal distention

  • Pelvic or lower quadrant mass

  • Localized to diffuse peritonitis if freely perforated

  • May present as large bowel obstruction

Laboratory Findings

• • Leukocytosis

  • Stool may be guaiac positive

Imaging Findings

• • Abdominal x-ray: May show free abdominal air if a diverticulum has freely perforated

  • Radiographic picture of ileus or bowel obstruction

  • CT (oral and IV contrast)

  • -Effacement of pericolonic fat

    -Abscess

    -Fistula

    -Bowel wall thickening

  • Abscesses found on CT may be concomitantly percutaneously drained

  • Avoid colonoscopy (because of risk of perforation)

  • Water soluble contrast enema: May reveal abscess, fistula, extrinsic compression by a paracolic mass

• • Colonic/visceral malignancy

  • Appendicitis

  • Renal colic

  • Other causes of bowel obstruction

  • -Stricture

    -Incarcerated hernia

    -Internal hernia

  • Crohn disease

  • Ulcerative colitis

  • Ischemic colitis

  • Antibiotic-associated colitis

  • Irritable bowel syndrome

Rule Out

• • Colonic malignancy

  • Perforated carcinoma

  • Appendicitis

• • Plain x-ray to evaluate for free abdominal air

  • Contrast CT scan with percutaneous catheter drainage if abscess identified and accessible

  • Avoid colonoscopy or barium enema with acute presentation

When to Admit

• • Signs of peritonitis or severe abdominal pain

  • Mild attacks (noncomplicated) without signs of peritonitis or other indicators of perforation or obstruction may be managed as outpatient

  • Signs of sepsis, obstruction, fistulas

• • Mild to moderate cases may be treated as outpatient with oral antibiotics

  • NPO, IV hydration

  • IV broad-spectrum antibiotics

  • Percutaneous drainage if abscess found on CT

  • NG decompression

  • Avoid opioid pain medications

  • May perform colonoscopy a week or so after acute process subsides

Surgery

Indications

• • Emergency surgery

  • -Free perforation

    -Peritonitis

    -Massive bleeding

    -Complete obstruction

  • Urgent surgery

  • -Failure of ...