Diverticulitis Deconstructed
Overview
Before diving into the specifics of diverticulitis and its clinical work-up we will need to review some associated terms and their definitions. First, Diverticula are the outpouchings along the mucosal wall of the colon which occur naturally in patients. Second, diverticulosis is the refers to the presence of uninflamed diverticula and is the most common cause of lower GI bleeding. Lastly, diverticulitis are inflamed diverticula which result from obstruction/infection of these outpouchings.
Pathophysiology
The Sigmoid colon is the most common area for diverticula to occur due to high intraluminal pressure. Additional risk factors include low fiber diet, constipation, and obesity.
Clinical Manifestation
Patients with diverticulosis are usually asymptomatic and discovered incidentally. Once obstructed the diverticula become distended and can lead to left lower quadrant (LLQ) discomfort which is the most common clinical symptom of diverticulitis. Additionally, patients may present with fever, nausea, vomiting, diarrhea, constipation and bloating.
Diagnosis
CT abdomen/pelvis is the test of choice to diagnose diverticulitis. A barium enema could also provide a diagnosis, however, these should not be performed in the acute phase. Patients may also have increased WBC count or positive guaiac test.
Treatment
After diagnosis of acute diverticulitis patients should be remain NPO and started on antibiotics to treat the infection. Ciprofloxacin or Bactrim combined with Metronidazole should be provided to these patients as well as IV fluids. Patients should slowly advance their diet from NPO to clear liquids and then regular diet.
Patients with known diverticulosis should be advised to follow a high fiber diet or obtain fiber supplements. Roughly 90% of patients with a positive guaiac test 90% experience bleeding resolution. In cases of continued bleeding patients may be given vasopressin to help facilitate hemorrhage resolution.
Quiz Question
A 62-year-old man presents with left lower quadrant abdominal pain, fever, and leukocytosis. CT scan of the abdomen shows colonic diverticula with surrounding fat stranding, but no abscess or free air. He is hemodynamically stable and tolerating oral intake. Which of the following is the most appropriate initial management?
A. Immediate surgical resection
B. Clear liquid diet and oral antibiotics
C. Colonoscopy to confirm the diagnosis
D. High-fiber diet and NSAIDs
E. IV antibiotics and hospital admission for all patients
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The correct answer is B. Clear liquid diet and oral antibiotics