Commun signs and symptoms of Acute Diverticulitis and treatment

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Elsevier ClinicalKey Clinical Overview

Diagnosis Acute lower left quadrant abdominal pain (most commonly); right-sided pain can occur in some cases More generalized abdominal pain may occur with peritonitis Constitutional symptoms Fever Chills Other gastrointestinal symptoms Nausea or vomiting Abdominal mass Constipation or diarrhea Flatulence or bloating Urinary symptoms (eg, dysuria, urgency, frequency) can occasionally occur Rarely, there may be concurrent diverticular bleeding with blood in stool Complicated diverticulitis presents with typical features of underlying pathology (eg, abscess, fistula, obstruction, free perforation)

Synopsis Diverticulitis involves microperforation of a diverticulum, with ensuing localized inflammation contained by pericolic fat and mesentery Constipation and a Western diet of highly refined, low-fiber foods are thought to be major contributing factors to diverticulosis Diagnosis of acute diverticulitis can usually be made on the basis of history and physical examination Lower left quadrant tenderness may be present, but right-sided signs do not preclude diagnosis; low-grade fever is common CT of abdomen/pelvis is the imaging test of choice for confirming the diagnosis Conservative (nonsurgical) management of uncomplicated diverticulitis, with or without oral antibiotic therapy, results in resolution in most patients All patients with complicated diverticulitis require treatment with oral or IV antibiotics Patients who have severe or complicated diverticulitis or whose condition does not respond to medical therapy often require surgical intervention

Diagnosis Lower left quadrant tenderness may be present, but right-sided signs do not preclude diagnosis Right-sided diverticulitis is often confused with appendicitis Low-grade fever is common (may be absent in older adults [eg, those aged 65 years or older]) Signs of peritoneal inflammation (eg, muscle guarding, rebound tenderness) are absent with uncomplicated diverticulitis With peritonitis Generalized tenderness with rebound and guarding on abdominal examination Abdomen may be distended and tympanic to percussion Bowel sounds may be diminished or absent Older adults and some patients taking corticosteroids may have unremarkable findings, even in the presence of severe diverticulitis

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Kuemmerle, John F. (2024). In Goldman-Cecil Medicine (pp. 951). DOI: 10.1016/B978-0-323-93038-3.00128-3

The majority of patients with colonic diverticulosis are asymptomatic. Patients with diverticulitis commonly present with localized pain, fever, and anorexia. The pain may radiate to the back, flank, or suprapubic region. Nausea and vomiting, constipation or diarrhea, or urinary symptoms may be variably present. Physical examination typically reveals left lower quadrant tenderness, sometimes with localized guarding or a palpable mass. Rebound tenderness or peritoneal signs should suggest the presence of free perforation. Visible diverticular bleeding is rare in the setting of acute diverticulitis. Leukocytosis is present. When the acutely inflamed diverticulum is adjacent to the bladder, sterile pyuria may be found.

Perforated diverticulitis with rupture of fecal material into the full peritoneum is a life-threatening surgical emergency. For diverticulitis with purulent but non-fecal peritonitis, randomized trials comparing laparoscopic peritoneal lavage with surgical resection have shown essentially no difference in outcomes.For diverticulitis with focal abscess formation, treatment is percutaneous CT-guided drainage and subsequent surgery, usually laparoscopic, typically after 6 weeks.Uncomplicated acute diverticulitis is usually treated with antibiotics, but antibiotics have limited benefit.A 7- to 10-day course of oral antibiotics (e.g., amoxicillin–clavulanate[500 mg/125 mg] alone or ciprofloxacin [750 mg twice daily] plus metronidazole [500 mg four times daily]), perhaps after a single IV dose of antibiotics, is as effective and safe as hospitalization for IV antibiotics.Patients who can tolerate clear liquids can be treated in the outpatient setting with gradual advancement of their diet. Patients who are unable to tolerate eating should be admitted to the hospital for IV fluids and antibiotics (e.g., levofloxacin 750 mg daily and metronidazole 500 mg every 6 hours or piperacillin–tazobactam 3.375 g every 6 hours). For diverticular and other intra-abdominal infections that have had adequate surgical treatment, fixed-duration antibiotic therapy of approximately 4 days provides similar outcomes to longer courses until after the resolution of physiologic abnormalities (about 8 days).Although the risks associated with one episode of uncomplicated diverticulitis are low, with a mortality rate that is less than 1%, complicated diverticulitis, defined as diverticulitis with abscess, fistula formation, free perforation, or obstruction, is associated with increased inpatient morbidity in up to 25% of cases and has a mortality rate as high as 5%. Furthermore, these risks increase with a second episode of complicated diverticulitis.

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Long B, Werner J, Gottlieb M. The American Journal of Emergency Medicine. 2024;76:1-6. doi:10.1016/j.ajem.2023.10.051.

Publish date: February 4, 2024.

INTRODUCTION: Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION: Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with acute diverticulitis.