The white blood cell count usually is elevated with a predominance of polymorphonuclear cells. Immature band forms may be present. An acute abdominal radiographic series should be obtained in all patients with significant abdominal pain and suspected diverticulitis to identify pneumoperitoneum if macro-perforation has occurred.
Otherwise, findings often are nonspecific and include small or large bowel dilation or ileus, or evidence of bowel obstruction. CT with intravenous and oral contrast is the test of choice to confirm a suspected diagnosis of diverticulitis. The arrowhead sign consists of focal thickening of the colonic wall with an arrowhead-shaped lumen pointing to the inflamed diverticula Figure 2 Figure 2.
Although the sensitivity is excellent 97 percent , a normal CT does not preclude the diagnosis. Computed tomographic scan revealing marked eccentric thickening of the wall of the ascending colon and pericolic inflammatory fat and fascia white arrowheads. Fecal material is seen at the center of the inflammatory complex indicating an inflamed diverticulum black arrows.
Colonic diverticulitis diagnosed by computed tomography in the ED. Am J Emerg Med ; Computed tomographic scan showing eccentric thickening of the colon wall with arrowhead-shaped lumen contrasted by air arrow. Uncommonly, ultrasonography is used to confirm the diagnosis, primarily in patients with right-sided pain in whom other diseases e.
In such cases, ultrasonography reveals a hypoechoic or anechoic structure protruding from a segmentally thickened colonic wall. Ultrasonography was found to have a specificity of Although barium enema was used commonly in the past, it is no longer recommended because of the risk of extravasation of contrast material if perforation has occurred.
If barium enema is performed, water-soluble contrast should be used. Typical findings include spiculation of the mucosa, spasm, abscess, or evidence of frank perforation. Because of the theoretic potential to exacerbate perforation, endoscopic examination is acutely contraindicated unless inflammatory bowel disease, ischemic colitis, or carcinoma is highly suspected.
The severity of the inflammatory and infectious processes, as well as the underlying health of the patient, determines the appropriate treatment for patients with diverticulitis. In patients with uncomplicated diverticulitis who are clinically stable and able to tolerate fluids, outpatient treatment with broad-spectrum antibiotics covering anaerobes and gram-negative rods is appropriate Table 3 Table 3 6. Common choices are metronidazole Flagyl plus a quinolone; metronidazole plus trimethoprim-sulfamethoxazole Bactrim, Septra ; or amoxicillinclavulanic acid Augmentin.
Morphine Duramorph should be avoided if possible because of its propensity to increase intracolonic pressure. Close follow-up is recommended, and hospitalization should be considered if the patient experiences increasing pain, fever, or an inability to tolerate fluids.
Antibiotic treatment should be continued for seven to 10 days. Hospitalization is recommended if patients show signs of significant inflammation, are unable to take oral fluids, are older than 85 years, or have significant comorbid conditions.
These patients should be placed on bowel rest and treated with intravenous fluids and intravenous antibiotics Table 3 Table 3 6. Appropriate choices, based on expert consensus rather than randomized trials, include anaerobic coverage with metronidazole or clindamycin Cleocin and gram-negative coverage with an aminoglycoside, a monobactam, or a third-generation cephalosporin.
Nasogastric suction is not indicated unless there is significant ileus. As with patients receiving out-patient therapy, hospitalized patients should improve within 48 to 72 hours.
The diet then can be advanced, and the patient discharged to complete a seven- to day course of oral antibiotics. Third-generation cephalosporin ceftriaxone [Rocephin], ceftazidime [Fortaz], cefotaxime [Claforan]. Beta-lactamase inhibitor combinations ampicillin-sulbactam [Unasyn], ticarcillin-clavulanate [Timentin]. Information from reference 6. Most patients with acute diverticulitis respond to conservative medical management, although 15 to 30 percent may require surgery during hospital admission because of lack of response to treatment or because of development of complications.
After a second episode, the probability of a third episode surpasses 50 percent, and subsequent attacks are less likely to respond to medical therapy and also have a higher mortality rate. Several surgical options are available, including resection with primary anastomosis, resection with colostomy and closure of the rectal stump, transverse colostomy and drainage, and laparoscopic colectomy. Complications of diverticulitis include abscess, fistula, bowel obstruction, and free perforation.
These complications all require surgical consultation. Abscesses occur when the pericolic tissues fail to control the spread of the inflammatory process. Abscess formation should be suspected when fever, leukocytosis, or both persist despite an adequate trial of appropriate antibiotics.
A tender mass may be palpable on physical examination. If right upper quadrant pain or elevated transaminase levels occur, evidence of a pyogenic liver abscess should be sought. CT-guided percutaneous drainage may be appropriate for small abscesses or while patients with sepsis are being stabilized for surgery. Peridiverticular abscesses can progress to form fistulas between the colon and surrounding structures in up to 10 percent of patients.
Colovesical fistulas are the most common variety and require surgery for treatment. Fistulas involving the bladder are more common in men; in women, the uterus is interposed between the colon and the bladder. Intestinal obstruction is uncommon in diverticulitis, occurring in approximately 2 percent of patients. The small bowel is affected most often, and obstruction usually is caused by adhesions. The colon can become obstructed because of luminal narrowing caused by inflammation or compression by an abscess.
Multiple attacks can lead to progressive fibrosis and stricture of the colonic wall. Obstruction generally is self-limited and responds to conservative therapy. If persistent, obstruction of the colon can be treated by a variety of endoscopic and surgical techniques.
Free perforation with peritonitis is rare, but it carries a mortality rate as high as 35 percent and requires urgent surgical consultation. If generalized peritonitis develops, the mortality rate is even higher. Perforation has been linked to nonsteroidal anti-inflammatory drug NSAID use in case-control studies. Steroids also may mask symptoms and delay appropriate therapy.
The 1-year risk for C. Healio News Primary Care Gastroenterology. By Janel Miller. Ann Intern Med. Please see the study for all other authors' relevant financial disclosures. Read next. B Extensive segment sigmoid diverticulitis arrows demonstrating multiple diverticula with pericolonic inflammation. Ultrasonography has good diagnostic accuracy for diverticulitis compared with CT; however, it is inferior to CT for estimating the extent of large abscesses and for evaluating for free air.
MRI has good diagnostic accuracy. However, MRI takes significantly longer than CT and may not be acceptable in critically ill patients. Colonoscopy is contraindicated in acute diverticulitis, but historically was recommended to be performed four to six weeks after resolution of acute diverticulitis to confirm the diagnosis and to exclude other causes e. The decision to hospitalize a patient with uncomplicated diverticulitis depends on several factors, including the patient's ability to tolerate oral intake, severity of illness, comorbidities, and outpatient support systems.
Inpatient management includes no food or drink by mouth, intravenous fluid resuscitation normal saline or lactated Ringer solution , and intravenous antibiotics. The usual practice in the United States for the treatment of diverticulitis includes broad-spectrum antibiotics against gram-negative rods and anaerobic bacteria Table 4.
A study randomized patients to antibiotics or placebo and found that antibiotic therapy for uncomplicated diverticulitis did not accelerate recovery, prevent complications, or prevent recurrence. Not recommended in mild, uncomplicated diverticulitis; recent trials suggest that taking no antibiotics is an option with appropriate follow-up 23 , Ciprofloxacin Cipro , mg orally every 12 hours, or levofloxacin Levaquin , mg orally every 24 hours, plus metronidazole Flagyl , mg orally every six hours.
Ciprofloxacin, mg IV every 12 hours, or levofloxacin, mg IV every 24 hours, plus metronidazole, mg IV every six hours or1 g IV every 12 hours. Ampicillin, 2 g IV every six hours, plus metronidazole, mg IV every six hours, plus ciprofloxacin, mg IV every 12 hours, or levofloxacin, mg IV every 24 hours. Ampicillin, 2 g IV every six hours, plus metronidazole, mg IV every six hours, plus amikacin, gentamicin, or tobramycin.
Information from references 22 through Patients with a localized abscess may be candidates for CT-guided percutaneous drainage, a procedure that does not increase the risk of recurrent diverticulitis. It should be used to stratify a patient's risk before surgery Table 5. Cloudy, purulent. Br J Surg. Risk factors for diverticulitis include use of nonsteroidal anti-inflammatory drugs, increasing age, obesity, and a sedentary lifestyle.
Patients who present with symptoms consistent with recurrent diverticulitis warrant a complete evaluation. Studies have shown recurrence rates of diverticulitis from 9 to 36 percent. In a large retrospective study involving 3, patients treated for diverticulitis with a mean follow-up of nine years, 9 percent had one recurrence and 3 percent had more than one recurrence after initial nonoperative management.
A retrospective study analyzing consecutive patients with diverticulitis found the five-year recurrence rate was 36 percent, with 3. Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, and, in persons with a body mass index of 30 kg per m 2 or higher, weight loss.
Data Sources: A PubMed search was completed in Clinical Queries using the key terms diverticulitis, diverticulosis, diverticular disease, pathogenesis, diagnosis, and treatment. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews.
Search date: April 15, Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Reprints are not available from the authors. Acute diverticulitis. N Engl J Med. Diagnosis and management of diverticular disease of the colon in adults. Am J Gastroenterol. The burden of selected digestive diseases in the United States. Diverticulitis in the United States: — changing patterns of disease and treatment. Ann Surg. Cyclical increase in diverticulitis during the summer months.
Arch Surg. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. The genetic influence on diverticular disease — a twin study. Aliment Pharmacol Ther. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding.
A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Acute left colonic diverticulitis: a prospective analysis of consecutive cases.
Rebound tenderness test. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy.
Eur Radiol. Diagnostic imaging for diverticulitis. J Clin Gastroenterol. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Right now, your colon needs rest — and the less irritation it endures, the better. Your doctor will likely advise a liquid diet for a few days so your digestive tract can begin healing, and then you can gradually reintroduce low-fiber solid foods back into your diet, such as eggs, fish, green beans, carrots, white rice, refined white bread, and poultry.
Foods and drinks to consume might include: The upside to a liquid diet is that you might temporarily drop a few pounds. In fact, this is one of the fastest ways to deliver medication and fluids to the body. But if diverticulitis progresses, your doctor may start discussing the possibility of surgery. The purpose of surgery is to remove sections of the colon affected by the condition. One option is a primary bowel resection, which removes the diseased section of the colon and reconnects healthy sections so that you can retain normal bowel function.
Your surgeon can perform this procedure with open surgery or a laparoscopic procedure. This procedure is a bit more intense and involves the creation of a hole or opening for the large intestines through the abdominal wall.
Your surgeon attaches a bag to the end of this opening, which collects waste. If you develop an abscess, which is a pocket of pus, it may heal on its own with antibiotics, or your doctor can drain it during surgery. Diet can play a role in treating and preventing attacks. So to keep your bowels functioning properly, you may need to drink more fluids and add more fiber.
In fact, those eating red meat once per day have 25 times the risk of developing diverticulitis compared with those who eat it once per week or less. As far as foods to avoid, some people believe they must avoid nuts or seeds to prevent diverticulitis. Motola explains that contrary to popular belief, ingesting nuts, corn, popcorn, and presumably seeds is not associated with an increased risk of diverticular disease.
Bulsiewicz agrees. Diverticulitis can be painful and scary, and may require a hospital stay, but with antibiotics, pain medications, and sometimes surgery, the colon can heal.
Move it. Find activities that you enjoy and get moving. The Centers for Disease Control and Prevention advises adults to get minutes of moderate-intensity exercise such as brisk walking per week, or 75 minutes of vigorous-intensity aerobic activity such as running, biking, or swimming per week.
Fuel up with fiber.
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