Diverticulitis
Diverticulosis
Diverticulitis
William V. Harford, Jr, MD
University of Texas Southwestern Medical Center, Dallas, TX
Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References
Definition/Key Clinical Features
Inflammation of diverticula
- Small herniations of colonic mucosa and submucosa through the muscularis propria
- Occurs in 10%-25% of patients with known diverticulosis
- Abdominal pain and localized tenderness, usually in left lower quadrant
- Anorexia
- Nausea without vomiting
- Diarrhea or constipation caused by colonic inflammation
- Low-grade fever
- Complications
- Phlegmon
- Abscess
- Perforation
- Bacteremia
- Sepsis syndrome
- Fistula formation
Differential Diagnosis
- General Population
- Appendicitis
- Mesenteric adenitis
- Crohn disease
- Meckel diverticulitis
- Infectious colitis or ileitis
- Small-bowel obstruction
- Perforated peptic ulcer
- Acute cholecystitis
- Acute pancreatitis
- Urinary tract infection
Women of Childbearing Age
- PID
- Rupture of ovarian follicle or cyst
- Ruptured ectopic pregnancy
- Ovarian torsion
Middle-Aged to Elderly Patients
- Ischemic colitis
- Perforated cancer of right colon
Young Children
Best Tests
- If symptoms are mild and respond to empirical therapy, defer x-rays
- History and physical exam are often sufficient for a presumptive diagnosis
- In women of childbearing age, perform pelvic and abdominal ultrasound
- Plain abdominal x-ray to exclude other abdominal conditions
- If symptoms are severe, perform the following:
- Plain abdominal x-ray to exclude abdominal obstruction or perforated bowel
- Abdominal CT with oral and I.V. contrast
- After acute symptoms have resolved, consider colonoscopy or barium enema to exclude cancer and inflammatory bowel disease
Best Therapy*
- For mild symptoms, recommend liquid diet or low-roughage diet
- If symptoms are severe or if there is concern for intra-abdominal infection, get surgical consultation
- Antibiotic therapy
- High-fiber diet may be useful for prevention
Antibiotic Therapy for Diverticulitis
- Amoxicillin-clavulanate
- For mild diverticulitis
- Dose: 875/125 mg p.o., q. 12 hr × 7 d
- Sulfamethoxazole-trimethoprim + Metronidazole
- For mild diverticulitis
- Dose: 1 double-strength SMX-TMP b.i.d. + 500 mg metronidazole p.o., q. 8 hr × 7 d
- Ciprofloxacin + Metronidazole
- For mild diverticulitis
- Dose: 500 mg ciprofloxacin p.o., q. 12 hr, + 500 mg metronidazole p.o., q. 8 hr × 7 d
- Levofloxacin + Metronidaxole
- For mild diverticulitis
- Dose: 750 mg levofloxacin p.o., q. 12 hr, + 500 mg metronidazole p.o., q. 8 hr × 7 d
- Ampicillin-sulbactam
- For severe/complicated diverticulitis
- Dose: 1.5-3.0 g I.V. q. 6 hr
- Cephalosporin Alone
- For severe/complicated diverticulitis
- Cefotetan
- Cefoxetin
- Cefotetan + Gentamicin
- For severe/complicated diverticulitis
- Dose: 1 g cefotetan q. 12 hr (or 400-900 mg clindamycin q. 8 hr for penicillin-allergic patients) + 5-7.5 mg/kg gentamicin in single daily dose
- Metronidazole + Ceftriaxone
- Dose: 500 mg metronidazole I.V. q. 6 hr + 1 g ceftriaxone I.V. q. 24 hr
Best References
American Society of Colon and Rectal Surgeons: Dis Colon Rectum 49:939 2006 [PMID 16741596]
Kaiser AM, et al: Am J Gastroenterol 100:910 2005 [PMID 15784040]
Macias LH, et al: Am Surg 70:932 2004 [PMID 15529855]
The author has no commercial relationships with manufacturers of products or providers of services discussed in this module.
* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=
February 2010
Diverticulosis
William V. Harford, Jr, MD, FACP
University of Texas Southwestern Medical Center, Dallas, TX
Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References
Definition/Key
Clinical Features
- Defined as condition of having diverticula in the colon, which are herniations of colonic mucosa and submucosa that extend through the muscularis propria
- Occurs where perforating arteries traverse the circular muscle layer and form parallel rows between the mesenteric and antimesenteric taenia
- Common condition; of persons with known diverticulosis, about 10 to 20% will develop diverticulitis or diverticular bleeding
- Uncommon before the age of 40 and increases in incidence after that age
- Women are two to three times more likely than men to report having condition, and whites are more likely than African Americans
- Diverticula occur predominantly
- In left colon, particularly the sigmoid colon, which is involved in 95% of cases, in Western countries
- In right colon in Far East, including Japan
- Diverticular disease imposes a considerable and increasing clinical burden on the US population, with over 300,000 admissions and 1.5 million days of inpatient care annually
- Risk of diverticulitis increases with age and with the use of nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and opioids
- Reduced colonic diameter and reduced colonic wall compliance are felt to predispose persons to condition
- Common in countries where a low-fiber diet is consumed where high-fiber diet reduces the risk of diverticular disease
- Changes in bacterial colonic microflora have been reported in patients; may lead to low-grade chronic inflammation, predisposing to the development of diverticulitis
- Complications include
- Diverticulitis
- Intestinal obstruction
- Diverticular hemorrhage; most common cause of lower GI bleeding
Differential Diagnosis
- Irritable bowel syndrome
- Colon cancer
- Inflammatory bowel disease
- Mesenteric ischemia
Best Tests
- Colonoscopy
- Test of choice; rules out colon cancer, ischemia, and inflammatory bowel disease
- Contraindicated in active diverticulitis
- Computed tomographic (CT) scan helps show complications, such as perforations and abscesses
- Barium enema useful in diagnosis but contraindicated in acute diverticulitis or perforation
- Abdominal x-ray can rule out major illnesses such as bowel obstruction
Best Therapy*
- Most patients have minimal or no symptoms and do not require any specific treatment
- Dietary therapy
- High-fiber diet and fiber supplements
- Advisable to prevent constipation and the formation of more diverticula
- No scientific data support the recommendation to avoid seeds, nuts, corn
- Antibiotic therapy
- Usually needed when diverticulitis occurs; oral antibiotics are sufficient when symptoms are mild; examples of commonly prescribed antibiotics include
- Amoxicillin-clavulanate
- Metronidazole
- Ciprofloxacin + metronidazole
- Levofloxacin + metronidazole
Best References
Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Ann Surg 2009;249:210–7. [PMID: 19212172]
Ludeman L, Warren BF, Shepherd NA. Best Pract Res Clin Gastroenterol 2002;16:543. [PMID: 12406450]
Tursi A. Gastroenterology 2004;127:1865. [PMID: 15578538]
West AB; National Diverticulitis Study Group (NDSG). J Clin Gastroenterol 2008;42:1137–8. [PMID: 18936652]
The author has no commercial relationships with manufacturers of products or providers of services discussed in this module.
* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=
February 2010
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