inpatient / gastroenterology


Last Updated: 1/21/2023

# *** Uncomplicated/Complicated Diverticulitis

Complicated if : bowel obstruction, abscess, fistula, perforation; imaging of inflammation, fat-strianding, etc is un-complicated
Consider Abx in uncomplicated if: 
fevers, WBC >15, CRSP >140, immunosuppressed, significany co-morbidities, symptoms >3-5 days

-- ABCs: profound hypotension or evidence of peritonitis gets STAT surgery consult
-- Chart Check: prior surgeries, abdominal infection, co-morbidities, immunosuppression,
-- Admission Orders: clear liquid diet vs NPO
-- Initial Treatment: fluids, tylenol and dicylcomine, antibiotics if needed

-- History: *** known diverticulosis, last colo, immunocompromised
-- Clinical: *** LLQ pain, fever, anorexia, diarrhea or constipation
-- Exam: *** fever, LLQ abd pain, evidence of peritonitis
-- Data: *** WBC, CTAP 
-- Etiology/DDx: *** LLQ pain - UTI, nephrolithiasis, pregnancy, gastroenteritis, ischemia, hernia, malignancy, IBD, appendicitis, ileus/obstruction

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- CTAP with IV contrast if concern for complicated diverticulitis or not improving in 2-3 days
-- Abx: *** Uncomplicated - can consider 7 days PO cipro/flagyl, bactrim/flagyl or augmentin; Complicated - IV Zosyn with transition to PO for 10-14 day course
-- Palliative: *** tylenol, dicylcomine, zofran PRN
-- IVF: ***
-- Bowel Rest → high fiber diet
-- If complicated - surgical consult, IR consult to drain an abscess, etc
-- Colonoscopy 6 weeks after the acute event (if not done in the last year) to assess for malignancy

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If You Remember Nothing Else

Diverticulitis is an infection of a colon diverticula, most commonly located on the left-side of the sigmoid colon. Historically, all-comers with diverticulitis have historically been treated with antibiotics; however recent data and guidelines suggest that foregoing antibiotics in uncomplicated diverticulitis is non-inferior to treating and does not prolong length of stay. If you do end up treating, it should be 7 days of PO antibiotics and based on clinical judgement. If the patient has complicated diverticulitis (bowel obstruction, asbcess, fistula, perforation), it should be treated with IV broad spectrum antibiotics that cover GNRs and anaerobes and should involve surgical teams.

Clinical Pearls

  • Stercoral colitis is inflammation of the colonic wall due to pressure from impacted fecal material leading to ischemic pressure necrosis - disimpact and consider abx if septic 
  • Risk factors for diverticulosis include low fiber diet, constipation, obesity, sedentary lifestyle, smoking, NSAIDs, red meat consumption
  • 90% of diverticuli in pts in western populations are left-sided in the sigmoid colon 
  • 75% of diverticulosis bleeding will be self-limited and resolve on own
  • Diverticulitis occurs in 4% of patients with diverticulosis - infection of diverticuli, often due to micro-perforations 
  • About 5-15% of patients with diverticulitis go on to develop abscess or fistula whereas obstruction or frank perforation are much less common
  • 90% of diverticuli in pts in western populations are left-sided in the sigmoid colon 
  • Diverticulosis can cause painless bleeding of vasa recta at the site of herniation into muscularis propria

Trials and Literature

  • STAND Study - foregoing abx does not prolong LOS in patients with uncomplicated diverticulitis; caveats - done in New Zealand and Australia and all patients had CT scans proving that the diverticulitis was not complicated before randomization and the decision was made to not give antibiotics (Clin Gastroenterol Hepatol, 2021)
  • AVOD Study - antibiotic avoidance for uncomplicated diverticulitis is safe in the long term - no difference in recurrence, complications, need for surgery, dx of colon cancer (Br J Surg, 2019)
  • Meta-Analysis of Abx in Diverticulitis - abx reduce treatment failure but do not affect mortality, recurrence, or readmission; NNT 32 (prevent treatment failure), NNH 24 (reaction to abx)

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