Diverticulitis

40 y/o F with h/o low-fiber intake and diverticulosis presents in summer with acute onset abdominal pain. Reports fever, anorexia, nausea, LLQ abdominal pain (LR 3.3), dysuria. Denies vomiting (LR 1.4), regular physical activity. Medications include NSAIDs, steroids, and chronic PO analgesics. Obese with fever (LR 1.4), abdominal distention, and LLQ pain (LR 10.4) on exam. Hypoactive bowel sounds, abdominal rigidity, and rebound tenderness concerning for peritonitis.

  • Labs

    • Obtain BMP, U/A

    • CBC shows leukocytosis

    • C-reactive protein >50 mg/L

  • Imaging

    • Abdominal/pelvic CT with contrast shows inflamed diverticulum, arrowhead sign, fascial thickening, and free air

      • Abscess present: Consult for CT-guided percutaneous drainage; send aspirate for culture

      • Bowel obstruction, abscess, and/or perforation: Consult surgery and calculate mortality risk using Mannheim Peritonitis Index

    • Complicated disease: F/u 4-6 weeks s/p symptom resolution for colonoscopy

  • Treatment

    • Unable to tolerate PO, concern for complicated diverticulitis, and/or s/sx peritonitis: Admit  inpatient

    • NS at 125 cc/hr while NPO

    • Start metronidazole 500 mg IV q8 hours; transition to PO at discharge

    • Start ceftriaxone 2g IV qd; transition to ciprofloxacin 750 mg BID at discharge

  • Counseling

    • Pt advised that 30% of patients require abdominal surgery while admitted

    • Pt counseled that dietary fiber, exercise, weight loss, and smoking cessation can help prevent future episodes

    • Pt counseled that avoiding nuts, corn, and popcorn will not reduce risk of future episodes

Notes

  • Epidemiology

    • Diverticulitis admissions are more common during summer months

    • Women at 2x greater risk for complications

    • Chronic NSAIDs, corticosteroid, and/or opioid analgesics increase perforation risk

  • Diagnosis

    • Localized LLQ pain is the most predictive physical exam finding (LR 10.4)

    • Arrowhead sign: Triangular colonic wall thickening pointing to diverticulitis

  • Severity

    • Complicated diverticulitis

      • Associated with one of the following diagnoses: Obstruction, phlegmon, abscess, fistula, perforation

      • Indication for hospitalization and IV antibiotics

      • Refer to a local antibiogram due to increasing E. coli resistance against fluoroquinolones and some 3rd generation cephalosporins

    • Uncomplicated diverticulitis:

      • Does not meet qualifications for complicated diverticulitis (>90% of cases)

      • Can be managed outpatient with rest and fluids

      • Antibiotics do not improve outcomes