Rosen & Barkin's 5-Minute Emergency Medicine Consult (219 page)

• Abdominal (supine and upright) and chest radiographs
  
  • Perforation indicated by free air
    
  • Obstruction indicated by air–fluid levels
    
• CT
  
  • Diagnostic criteria include:
    
    • Wall thickening >5 mm
      
    • Inflammation of pericolic fat
      
    • Pericolic abscess
      
  • Nondiagnostic criteria include:
    
    • Stricture
      
    • Diverticula
      
    • Fistula
      
  • CT-guided percutaneous needle aspiration of localized abscesses avoids further surgery.
    
• Endoscopy
  
  • Not necessary to diagnose acute illness
    
  • Rigid sigmoidoscopy aids in diagnosing nondiverticular causes of abdominal pain (spasm, stricture, edema, pus, or peridiverticular erythema).
    
• US
  
  • For diagnosing colonic wall thickening, inflammation, mass, abscess, or fistula
    
  • Greatly operator dependent
    
  • Not reliable in presence of intestinal gas
    
• Barium enema
  
  • Indicated after resolution of acute illness to rule out fistula or other colonic pathology (e.g., carcinoma)
    

• Colon carcinoma with perforation
  
• Ischemic colitis
  
• Bacterial colitis
  
• Appendicitis
  
  • Left-sided pain if peritonitis from ruptured appendix
    
  • Right-sided diverticular pain with cecal diverticulum (rare) or redundant sigmoid colon
    
• Inflammatory bowel disease
  
• Irritable bowel syndrome
  
• Ruptured or torsed ovarian cyst
  
• Pancreatic disease
  
• Pelvic inflammatory disease
  
• Peptic ulcer disease
  
• Renal colic
  

TREATMENT

IV fluids

• Fluid resuscitation with 0.9% normal saline
  
• Bowel rest
  
  • NPO or clear liquid diet
    
  • Nasogastric tube (NG) tube if persistent vomiting or bowel obstruction suspected
    

• Uncomplicated diverticulitis
  
  • Most respond to medical therapy, but 30% may require surgery
    
• Complicated diverticulitis
  
  • Most require percutaneous drainage or surgery
    
• Analgesia
  
  • Anticholinergics (dicyclomine):
    
    • Reduces colonic spasm
      
    • Does not mask underlying pathology
      
  • Opiates for more aggressive pain management (theoretically increase intraluminal pressure, leading to perforation)
    
    • Do not use if hemodynamically unstable
      
• Antibiotics to cover gram-negative aerobic and anaerobic bacteria:
  
  • Mild, uncomplicated cases (peridiverticulitis) for outpatient management:
    
    • Ciprofloxacin or levaquin + metronidazole or clindamycin
      
    • Trimethoprim/sulfamethoxazole (TMP/SMX) DS + metronidazole
      
    • Amoxicillin/clavulanate
      
    • Duration of therapy is 10–14 days
      
  • Moderate uncomplicated and mild complicated cases for inpatient management:
    
    • Ceftriaxone or other 3rd-generation cephalosporin + metronidazole or clindamycin
      
    • Ampicillin/sulbactam
      
    • Piperacillin/tazobactam
      
    • Ticarcillin/clavulanate
      
    • Ciprofloxacin or levaquin + metronidazole or clindamycin
      
    • Aztreonam
      
  • Complicated cases (with peritonitis from perforation), consider:
    
    • Imipenem/cilastatin
      
    • Meropenem
      
    • Aztreonam + metronidazole or clindamycin
      
    • Gentamicin + metronidazole or clindamycin ± ampicillin
      
    • Trovafloxacin (alternative)
      
• Surgery:
  
  • Emergent surgery:
    
    • Indicated for generalized peritonitis from perforation
      
    • 2-stage procedure with resection of diseased segment of colon and proximal colostomy followed later with reanastomosis
      
  • Elective surgery:
    
    • Indicated for multiple recurrent attacks (>2) without generalized peritonitis (controversial); fistula formation; intractable pain; unresolved obstruction; failure of medical therapy; single serious attack in patient <50 yr of age (controversial)
      
    • 1-stage procedure following resolution of inflammation from medical therapy
      
    • Nonoperative management may be considered for complicated diverticulitis.
      
  • Peridiverticular abscess drainage:
    
    • Indicated if well circumscribed and easily accessible
      
    • Accomplished by CT- or ultrasound-guided percutaneous needle aspiration
      
• Outpatient therapy:
  
  • Clear liquids with follow-up in 2–3 days
    
  • When acute condition has resolved:
    
    • High-fiber, low-fat diet to decrease recurrence of attacks
      

• Amoxicillin/clavulanate: 500/125 mg PO TID or 875/125 mg PO BID
  
• Ampicillin: 2 g IV q6h
  
• Ampicillin/sulbactam: 3 g IV q6h
  
• Cefotetan: 2 g IV q12h
  
• Cefoxitin: 2 g IV q8h
  
• Ciprofloxacin: 400 mg IV q12h or 500 mg PO BID
  
• Dicyclomine: 20 mg PO QID (up to 40 mg PO QID) or 20 mg IM q6h (
  not
  for IV use)
  
• Gentamicin: Multiple daily dose (MDD) regimen, 2 mg/kg load, then 1.7 mg/kg IV q8h, or once-daily dose (OD) regimen, 5–7 mg/kg IV q24h (assuming normal renal function)
  
• Imipenem/cilastatin: 500 mg IV q6h
  
• Meropenem: 1 g IV q8h
  
• Metronidazole: 1 g (15 mg/kg) IV load then 500 mg IV q8h or 500 mg PO q8h
  
• Piperacillin/tazobactam: 3.375 g IV q6h or 4.5 g IV q8h
  
• Ticarcillin/clavulanate: 3.1 g IV q6h
  
• Trimethoprim/sulfamethoxazole DS: 1 tablet PO BID
  
• Trovafloxacin: 300 mg IV for 1st dose, then 200 mg IV/PO daily
  

• Uncomplicated diverticulitis (outpatient), 10–14 days
  
  • Amoxicillin–clavulanate 875/125 mg PO BID
    
  • Trimethoprim/sulfamethoxazole DS 1 tablet PO BID AND metronidazole 500 mg PO q6h
    
  • Ciprofloxacin 500 mg PO BID AND metronidazole 500 mg PO q8h
    
  • For patients intolerant of metronidazole, consider clindamycin
    
• Complicated diverticulitis
  
  • Ticarcillin/clavulanate: 3.1 g IV q6h or
    
  • Ampicillin/sulbactam: 3 g IV q6h or
    
  • Ceftriaxone 1 g IV q24h AND metronidazole 500 mg IV q8h
    
  • Levofloxacin 500 mg or 750 mg IV q24h (or ciprofloxacin 400 mg IV q12h) AND metronidazole 1 g IV q12h
    
  • Imipenem 500 mg IV q6h or meropenem 1 g IV q8h
    

FOLLOW-UP

• Intractable pain and/or vomiting
  
• High fever
  
• Peritonitis
  
• Failure to respond to outpatient management
  
• Severe disease on CT scan
  
• Significant leukocytosis
  
• Immunocompromised or steroid-dependent patients
  
• Recurrent episodes
  
• Comorbidities: Renal insufficiency, liver dysfunction, COPD, diabetes with end-organ damage
  
• Extremes of age
  
• Uncertainty of diagnosis
  

• Mild cases (low-grade fever, mild discomfort) of known diverticular disease
  
• Minimal comorbidities
  
• Tolerating PO
  

Massive diverticular bleeding requiring GI or surgical consultation

• Clear liquids
  
• Clinical improvement should be seen in 3 days, after which diet can be advanced
  
• Advise patients to call for increasing pain, fever, or inability to tolerate PO
  
• Colonoscopy (or contrast enema x-ray with flexible sigmoidoscopy) should be obtained after resolution of initial episode
  
• Patients do NOT need to avoid seeds and nuts
  

• CT scanning differentiates diverticulitis as complicated or uncomplicated:
  
  • Surgery reserved for complicated cases, but nonoperative management becoming more prevalent
    
• Most cases of uncomplicated diverticulitis rarely progress to complicated disease
  
  • Multiple attacks do not seem to lead to increased complications.
    
• Diverticulitis does not seem to be a progressively worsening process
  
  • Acute episodes can present at any stage.
    
• Severe disease on initial CT scan
  
  • Increased risk of failure of medical therapy
    
  • High risk of secondary complications
    

• Lorimer JW, Doumit G. Comorbidity is a major determinant of severity in acute diverticulitis.
  Am J Surg
  . 2007;193:681–685.
  
• Nelson RS, Ewing BM, Wengert TJ, et al. Clinical outcomes of complicated diverticulitis managed nonoperatively.
  Am J Surg
  . 2008;196(6):969–972.
  
• Rafferty J, Shellito P, Hyman NH, et al.; Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis.
  Dis Colon Rectum
  . 2006;49:939–944.
  
• Stollman NH, Raskin JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology.
  Am J Gastroenterol
  . 1999;94:3110–3121.
  
• Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis.
  Gastroenterol Clin North Am
  . 2009;38(3):513–525.
  
• Yoo PS, Garg R, Salamone LF, et al. Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis.
  Am J Surg
  . 2008;196:710–714.
  

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