7 Diverticulitis

Question 1

Remarks on epidemiology of diverticular disease

Answer 1

The prevalence of diverticulosis increases with age

Only 15% of patients with diverticulitis develop complicated disease. (The natural history of the disease appears to be more benign than previously believed.)

Question 2

Remarks on the management of diverticulitis

Answer 2

1. Although surgery played a prominent role in diverticulitis management in the past, most cases of diverticulitis can be managed medically.
2. In stable patients with a history of confirmed diverticulitis and a similar acute presentation, no further diagnostic evaluation is necessary unless the patient fails to improve with conservative medical management.
3. If a prior diagnosis has not been confirmed or the current episode differs from the past episode, diagnostic imaging is required to exclude other intra-abdominal pathology and to evaluate for complications

Question 3

Define diverticula

Answer 3

Diverticula are small herniations at site where the vasulature, called vasa recta, penetrates the circular muscle layer of the colon.

Diverticula usually range from 5 to 10 mm, but can extend up to 20 mm in length.

Question 4

Dominant bacteria isolated in diverticulitis

Answer 4

Bacteroides fragilis and E. coli

Question 5

Drugs that increase the risk of perforation in diverticulosis.

Answer 5

NSAIDs, opioids, and steroids

Question 6

Sidedness of diverticular disease

Answer 6

US: diverticular disease is almost exclusively a left-sided colon disease, specifically the descending and sigmoid colon

Asian: Right-sided disease is found predominantly in Asian populations
Schwartz: Right-sided diverticula occur more often in younger patients than do left-sided diverticula adn are *more common in people of Asian descent than in other populations*

Question 7

Pain in diverticulitis

Answer 7

The pain may be intermittent or constant
and is often assoc’d with a change of bowel habits, either diarrhea or constipation.

Question 8

Preferred imaging modality for diverticulitis

Answer 8

Abdominopelvic CT with IV contrast
CT is also preferred to detect complications.

Question 9

CT findings of diverticulitis

Answer 9

Increased soft tissue density within the pericolic fat (inflammation)
Presence of diverticula
Bowel wall thickening >4 mm
Soft tissue masses representing phlegmon
Pericolic fluid collections representing abscesses

Question 10

The 2015 American Gastroenterology Association recommendation on treatment of acute uncomplicated diverticulitis.

Answer 10

“that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis” confirmed by CT.

With increased understanding of the inflammatory rather than infectious etiology of uncomplicated diverticulitis, recent studies have reported no benefit to routine antibiotic use

Question 11

Remarks on use of antibiotics in diverticulitis

Answer 11

1. If antibiotics are warranted, a shorter duration of antibiotics (4 to 5 days) compared to the standard antibiotic course (7 to 10 days) may be appropriate)
2. There is no proven advantage of IV antibiotics over PO antibiotics for diverticulitis

Question 12

First line antibiotics for outpatient management

Answer 12

Metronidazole 500 mg PO QID
PLUS
Ciprofloxacin 750 mg PO BID
OR
Levofloxacin 750 mg PO daily
OR
Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1 double-strength tablet PO BID
OR
Cefuroxime 500mg PO BID

Question 13

Alternate antibiotics for outpatient management

Answer 13

Amoxicillin-clavulanate 875 mg 1 tab PO BID
OR
Moxifloxacin 400mg PO daily

Question 14

First line antibiotics for Moderate disease

Answer 14

Metronidazole 500mg IV q6h or 1g IV q12
PLUS
Cprofloxacin 400mg IV q12h
OR
Levofloxacin 750 mg IV q24h
OR
Aztreonam 2g IV tID
OR
Ceftriaxone 1-2g IV q24h
OR
Cefuroxime 1.5g IV q8h

Question 15

Alternate antibiotics for Moderate disease

Answer 15

Ertapenem 1 g IV q24h
Pip-taz 3.375 g IV q6h or 4.5 g IV q8h
Ticarcillin-clavulanate 3.1 g IV q6

Question 16

First line antibiotics for severe, life-threatening diverticulitis

Answer 16

Imipenem/cilastatin 500mg IV q6h
OR
Meropenem 1g IV q8h
OR
Pip-taz 4.5 mg IV q8h
OR
Ticarcillin-clavulanate 3.1 g IV q4h

Question 17

Alternate antibiotics for severe, life-threatening diverticulitis

Answer 17

Ampicillin 2g IV q6h
PLUS
Metronidazole 500mg IV q6h
PLUS
Ciprofloxacin 400mg IV q12h
OR
Amikcacin 15 mg/kg/day IV divided q12h

Question 18

Alternate antibiotics for severe, life-threatening diverticulitis with penicillin-allergy

Answer 18

Aztreonam 2g IV q6h
PLUS
Metronidazole 500mg IV q6h

Question 19

Dietary recommendations in diverticulitis

Answer 19

1. It is not necessary to limit the patients to a clear diet, but patients can be advised to eat foods as tolerated.
2. During the acute episode, our personal recommendations also include no dairy foods, because ability to process lactate can change, and no red meat, because it is difficult to digest

Question 20

Complicated diverticulitis is classified by

Answer 20

Hinchey classification scheme
Stage 1: small (<3 cm), confined pericolic or mesenteric abscesses
Stage 2: larger abscesses, extending to the pelvis

Stage 3: perforated diverticulitis and purulent peritonitis
Stage 4: free perforation with fecal contamination of the peritoneal cavity

Question 21

Phlegmon is

Answer 21

inflammation and infection of tissue without abscess

Question 22

Patients who can follow up with physician in _______ days are candidates for outpatient management +/- antibiotics

Answer 22

2-3 days

Question 23

Those who require inpatient management are

Answer 23

Those with complicated diverticulitis
- phlegmon
- abscess
- perforation
- fistula
- stricture
- obstruction
High-risk patients

Question 24

Some clinical high risk factors

Answer 24

Fever
Age >70 y/o
Active malignancy
Chronic opiate use
Corticosteroid use

Question 25

Diagnostic high risk factors

Answer 25

Generalized abdominal pain/ternderness Leukocytosis - WBC 11,000 CRP >9 mg/dL Signs of sepsis

Question 26

CT imaging high risk factors for progression to complicated diverticulitis

Answer 26

Fluid collections (frequently anterior to rectum) Greater length of inflamed colon (85 mm vs 65 mm) Inflamed diverticulum greater than 2 cm

Question 27

Observational treatment without antibiotics may be appropriate for

Answer 27

1) CT-confirmed, 2) uncomplicated, 3) acute diverticulitis 4) in **immunocompetent** patients 5) with **mild** symptoms 6) **without systemic** infectious signs or symptoms 7) or red flags for progression to complicated disease