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Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017
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Image courtesy of David Stein, MD.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Diverticula (shown) are small outpouchings of the gastrointestinal (GI) tract that can include all layers of the intestinal wall (true diverticula) or can exclude the muscular layer or adventitia (false diverticula or pseudodiverticula). Although they can be found throughout the entire GI tract, they are most common in the sigmoid colon and the left colon because of the higher intraluminal pressures in those areas.[1,2,3,4,5]
Image courtesy of Medscape (left) / Dreamstime | Rob3000 (right).
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
The presence of diverticula (especially colonic diverticula; shown) in the absence of inflammation is referred to as diverticulosis. Diverticulosis is a very common issue in the United States, as well as in industrialized countries across the world. Inflammation of these diverticula is referred to as diverticulitis. The exact mechanism of diverticulitis is not known; however, it has been shown that obstruction of a diverticulum can lead to vascular congestion and perforation.[3,6]
Image courtesy of Radiopaedia.org.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
In the United States, the incidence of diverticulosis (shown) increases proportionally with age, peaking at approximately 65% by age 85 years. It is thought that the greater the number of diverticula present, the higher the incidence of diverticulitis. Some 15-20% of patients with diverticulosis may develop diverticulitis during their lifetime.[5,7]
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
The computed tomography (CT) scan in the slide shows diverticulosis in a patient with carcinoma of the colon.
Which of the following is not a risk factor for the development of diverticulitis?
High-fat, low-fiber diet
Smoking
Aging
Daily exercise regimen
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Answer: D. Daily exercise regimen.
As previously discussed, age is a risk factor for the development of diverticulosis. Other risk factors include obesity; smoking; a high-fat, low-fiber diet; and lack of exercise. Certain medications are associated with an increased risk of diverticulitis, including steroids, opiates, and nonsteroidal anti-inflammatory drugs (NSAIDs). Although it is commonly believed that high-residue foods (eg, nuts and seeds) can cause diverticulitis, the data show that this is not the case.
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
A 55-year-old man comes to the emergency department (ED) complaining of left-lower-quadrant abdominal pain that was abrupt in onset and was accompanied by diarrhea. He has a low-grade fever. In the past, the patient underwent colonoscopy, which demonstrated the presence of diverticula.
Which of the following is not a common presenting symptom of uncomplicated diverticulitis?
Abdominal pain
Diarrhea
Hematemesis
Fever
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Answer: C. Hematemesis.
The clinical presentation of uncomplicated diverticulitis is variable, and the most common symptoms are fairly nonspecific. The symptom most commonly noted is abdominal pain. The pain is typically localized over the affected segment of colon, but it can become more diffuse as the diverticulitis worsens. Other frequently encountered symptoms are fever, diarrhea (with or without blood), and nausea. Clinical suspicion of diverticulitis should be increased if a patient presents with the aforementioned symptoms and has had a colonoscopy that revealed diverticulosis.[1,2,3,4,5,7,8]
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
A 52-year-old man presents to the ED with a complaint of acute onset of left-lower-quadrant abdominal pain, in association with low-grade fever and diarrhea. He is not in a toxic state, and his vital signs are stable. Moderate tenderness is noted over the left lower quadrant.
After routine laboratory studies have been ordered, what is the next step in diagnosis?
Barium enema
Abdominal ultrasonography
Colonoscopy
CT of the abdomen and pelvis
Image courtesy of Medical Body Scans / Science Source.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Answer: D. CT of the abdomen and pelvis.
The first step in making a diagnosis of acute diverticulitis consists of a focused history and physical examination. In view of the nonspecific symptoms in this case, however, steps should be taken to exclude other causes of abdominal pain (eg, urinary tract infection [UTI], inflammatory bowel disease [IBD], and nephrolithiasis). If diverticulitis is suspected, CT with oral and intravenous (IV) contrast is the most appropriate imaging modality. In cases of acute uncomplicated diverticulitis, CT typically shows segments of inflamed colon containing diverticula. CT can also be useful in cases of complicated diverticulitis; common findings include abscess formation, free air, fistula formation, and free extravasation of contrast.[1,2,7]
Image courtesy of Radiopaedia.org.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
A 42-year-old man with a history of diverticulosis presents to the ED with exquisite left-lower-quadrant pain and fever. The pain is progressively worsening and becoming more diffuse. The white blood cell (WBC) count is 20,000/µL. A chest radiograph obtained on arrival shows a small amount of free air under the diaphragm.
After initial resuscitation has been carried out, which of the following is the most appropriate next step in management?
Initiation of oral antibiotic therapy and discharge home
Urgent surgical consultation
Abdominal ultrasonography
Barium enema
Image courtesy of Medscape / Barry Slaven | Visuals Unlimited (inset).
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Answer: B. Urgent surgical consultation.
Management of complicated diverticulitis and severe uncomplicated diverticulitis requires procedural or surgical intervention. A contained diverticular abscess can be drained with the assistance of interventional radiology. For more severe cases, a range of surgical therapy is available and indicated. The traditional surgical treatment for severe or complicated diverticulitis is a Hartmann procedure (shown), which involves resecting the diseased segment of colon and creating an end colostomy. Another option is to perform laparoscopic lavage of the peritoneal cavity and place a drain without performing a colonic resection. This less invasive approach is gaining popularity among surgeons; however, formal guidelines on the use of laparoscopic lavage have not yet been established.[1,2,3,7]
Image courtesy of Barry Slaven | Visuals Unlimited.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Patients with complicated diverticulitis require urgent surgical evaluation. Common complications of acute diverticulitis include the following:
Microperforation
Localized abscess formation
Free perforation with diffuse peritonitis
Colonic stricture
Formation of fistulas to adjacent structures
The Hinchey classification helps stratify the severity of acute diverticulitis with perforation.[1,2,6]
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
A 42-year-old man with symptoms consistent with acute diverticulitis undergoes CT, which reveals acute sigmoid inflammation, as well as a 5-cm pelvic abscess.
What is the Hinchey classification of this perforation?
Class I
Class II
Class III
Class IV
Table adapted from Wieghard N et al.[8]
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Answer: Class II.
A distant (pelvic) abscess is present, but no purulent or fecal peritonitis is apparent.
Image courtesy of Medscape.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
The spectrum of possible therapies for diverticulitis is broad, and the choice among them depends to a large extent on disease severity. Patients with mild acute uncomplicated diverticulitis can be treated on an outpatient basis; oral antibiotic therapy with gram-negative and anaerobic coverage is initiated and continued for 7-10 days. Patients whose initial presentation is more severe or whose condition worsens during outpatient therapy should be admitted for inpatient treatment. IV antibiotics should be administered, and patients should be on NPO (nil per os) status until their condition improves. Antibiotics are continued for at least 7 days. Clinical deterioration is characterized by persistent fevers or leukocytosis, worsening findings on abdominal examination, and unstable vital signs. Repeat CT scans can be obtained for reassessment of disease severity.[1,2,7]
Image courtesy of David Stein, MD.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
The slide shows an intraoperative laparoscopic view of the takedown of a colovesical fistula.
Any patient who has had an episode of acute diverticulitis should undergo follow-up colonoscopy 6-8 weeks after symptoms have resolved. Colonoscopy is useful for planning possible colonic resection and for ruling out other causes of colonic inflammation that may be mimicking diverticulitis (eg, IBD and neoplasia). Colonoscopy should not be done any sooner than 6 weeks after resolution of symptoms; a procedure done too early increases the risk of colonic perforation.[1,2,7]
Images courtesy of David Stein, MD.
Diverticulitis: It’s (Sometimes) Complicated
Alexander Crean, MD; Edward Fazendin, MD; David Stein, MD | April 21, 2017 | Contributor Information
Although the indications for emergency colon resection for acute diverticulitis are well agreed upon, the indications for elective resection to prevent future episodes of diverticulitis are more controversial. A single episode of acute complicated diverticulitis has traditionally been accepted as a sufficient indication for performing an elective colonic resection, though this recommendation is currently being reevaluated in the surgical community. Multiple bouts of acute uncomplicated diverticulitis also have been considered to constitute an indication for elective colon resection, but there is no firm consensus on the number of episodes that must have occurred for colon resection to be warranted. Elective resection can be performed with open (left image), laparoscopic (right image), or robotic-assisted laparoscopic techniques, depending on the individual surgeon's preference and comfort level.[1,2,4,5,7,9]
Various pelvic-floor disorders can give rise to constipation or fecal incontinence. Learn more about diagnosing specific causes of abnormal defecation (eg, rectal prolapse, rectocele, dyssynergic defecation, levator syndrome).Slideshows, February 2017
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Contributor Information
Alexander Crean, MD
General Surgery Resident
Drexel University College of Medicine
Philadelphia, PA
Disclosure: Alexander Crean, MD, has disclosed no relevant financial relationships.
Edward Fazendin, MD
General Surgery Resident
Drexel University College of Medicine
Philadelphia, PA
Disclosure: Edward Fazendin, MD, has disclosed no relevant financial relationships.
David Stein, MD
Associate Professor of Surgery
Chief, Division of Colorectal Surgery
Drexel University College of Medicine
Philadelphia, PA
Disclosure: David Stein, MD, has disclosed no relevant financial relationships.
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References
Mulholland MW, Lillemoe KD, Doherty GM, et al. Greenfield's Surgery: Scientific Principles & Practice. Philadelphia: Lippincott Williams & Wilkins; 2012.
Cameron JL, Cameron AM. Current Surgical Therapy, Expert Consult - Online and Print. Philadelphia: Saunders; 2013.
Wieghard N, Geltzeiler CB, Tsikitis VL. Trends in the surgical management of diverticulitis. Ann Gastroenterol. 2015 Jan-Mar;28(1):25-30.
Shahedi K, Dea SK, Chudasama YN, Suraweera DB. Diverticulitis. Medscape Drugs & Diseases. Last Updated: June 17, 2016; Accessed April 14, 2017. Available at: http://emedicine.medscape.com/article/173388-overview.
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