Diverticulitis
Published on Dec 24, 2015
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PRESENTATION OUTLINE
goals for learning
- Staying or going?
- Antibiotics?
- Contrast?
My stomach hurts and I keep on throwing up.
74 yo F c/o generalized abdominal pain, nausea and vomiting. HPI.
Pertinent PMHx, PSHx, meds, allergies.
Pertinent PMHx, PSHx, meds, allergies.
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Where does diverticulitis come from?
5% incidence of diverticular disease in patients 70% by 85.
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Diverticula
Diverticulitis
Complicated Diverticulitis
Diverticula: Herniations of vasa recta through circular muscular layer in the colon.
Diverticulitis: Inflammation.
Complicated diverticulitis: Translocation of bacteria leads to micro-perforation, abscess or phlegmon formation.
Mainly anaerobes such as Bacteroides, Peptostreptococcus, Clostridium, Fusobacterium and G- rods like Escherichia coli.
NSAIDS, opioids, steroids increase risk of perforation.
Almost exclusively affects descending and sigmoid colon.
Diverticulitis: Inflammation.
Complicated diverticulitis: Translocation of bacteria leads to micro-perforation, abscess or phlegmon formation.
Mainly anaerobes such as Bacteroides, Peptostreptococcus, Clostridium, Fusobacterium and G- rods like Escherichia coli.
NSAIDS, opioids, steroids increase risk of perforation.
Almost exclusively affects descending and sigmoid colon.
How might a patient present?
Classic: LLQ, fever and WBC.
If redundant sigmoid colon, Asian or right sided disease, can have RLQ or suprapubic pain.
If redundant sigmoid colon, Asian or right sided disease, can have RLQ or suprapubic pain.
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naming the suspects
Table 82-1
Differential diagnosis
Acute appendicitis
Colitis—ischemic or infectious
Inflammatory bowel disease (Crohn's disease, ulcerative colitis)
Colon cancer
Irritable bowel syndrome
Pseudomembranous colitis
Epiploic appendagitis
Gallbladder disease
Incarcerated hernia
Mesenteric infarction
Complicated ulcer disease
Peritonitis
Obstruction
Ovarian torsion
Ectopic pregnancy
Ovarian cyst or mass
Pelvic inflammatory disease
Cystitis
Kidney stone
Renal pathology
Pancreatic disease
Differential diagnosis
Acute appendicitis
Colitis—ischemic or infectious
Inflammatory bowel disease (Crohn's disease, ulcerative colitis)
Colon cancer
Irritable bowel syndrome
Pseudomembranous colitis
Epiploic appendagitis
Gallbladder disease
Incarcerated hernia
Mesenteric infarction
Complicated ulcer disease
Peritonitis
Obstruction
Ovarian torsion
Ectopic pregnancy
Ovarian cyst or mass
Pelvic inflammatory disease
Cystitis
Kidney stone
Renal pathology
Pancreatic disease
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How do you make the diagnosis?
Pmhx of confirmed diverticulitis with similar presentation, no further dx workup needed unless fails conservative treatment.
If pmhx of diverticulitis non-confirmed or acute presentation, different, will need imaging.
CRP > 50 very suggestive of diverticulitis in patients with LLQ pain, no vomiting.
ESR has positive correlation to severity of disease. Higher in complicated cases.
If pmhx of diverticulitis non-confirmed or acute presentation, different, will need imaging.
CRP > 50 very suggestive of diverticulitis in patients with LLQ pain, no vomiting.
ESR has positive correlation to severity of disease. Higher in complicated cases.
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a picture is worth a thousand words
comparing imaging modalities
1. CT with IV and PO contrast: Se 97%, Sp 100%.
a) Findings: Increased soft tissue density within the pericolic fat, diverticula, bowel wall thickening > 4 mm, soft tissue masses (phlegmon), pericolic fluid collections (abscesses).
b) National Clearinghouse: Low-dose CT can reduce radiation dose by 75-90% but with similar Se and Sp. Retrospective review found no difference with contrast vs. non to diagnose acute abdominal process.
c) Low-dose unenhanced CT as accurate as standard IV contrast CT. Prospective cohort study. Se 90-100% Sp 95-99%.
2. US: Compression. If experienced, Se and Sp >80%.
a) Can drain abscess if present in appropriate setting.
b) Good for right-sided disease, pregnancy.
3. CT vs US: CT had a higher Se (81% vs 61%, p=0.048).
4. Unclear what role MRI has at this time. Not widely used, but similar in performance to CT.
a) Findings: Increased soft tissue density within the pericolic fat, diverticula, bowel wall thickening > 4 mm, soft tissue masses (phlegmon), pericolic fluid collections (abscesses).
b) National Clearinghouse: Low-dose CT can reduce radiation dose by 75-90% but with similar Se and Sp. Retrospective review found no difference with contrast vs. non to diagnose acute abdominal process.
c) Low-dose unenhanced CT as accurate as standard IV contrast CT. Prospective cohort study. Se 90-100% Sp 95-99%.
2. US: Compression. If experienced, Se and Sp >80%.
a) Can drain abscess if present in appropriate setting.
b) Good for right-sided disease, pregnancy.
3. CT vs US: CT had a higher Se (81% vs 61%, p=0.048).
4. Unclear what role MRI has at this time. Not widely used, but similar in performance to CT.
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Figure 82-1
Outpatient Antibiotic Treatment
Photo by Andres Rueda
Inpatient Moderate Disease
Life-threatening disease
are antibiotics in Uncomplicated diverticulitis
A thing of the past?
a) Infectious Diseases Society of America recommends a 4 day course of treatment.
b) Cochrane Review: 3 RCT’s. Not definitively conclusive, but promising that no antibiotics needed. No difference in surgery occurrence. Past RCT’s showed non-inferiority regarding antibiotic regimes and length of treatment.
c) American Gastroenterological Association Institute: For uncomplicated, non-sepsis, non-immunocompromised, few comorbidities, CT-confirmed inpatients, do not need antibiotics. Outpatient therapy has not been studied sufficiently.
b) Cochrane Review: 3 RCT’s. Not definitively conclusive, but promising that no antibiotics needed. No difference in surgery occurrence. Past RCT’s showed non-inferiority regarding antibiotic regimes and length of treatment.
c) American Gastroenterological Association Institute: For uncomplicated, non-sepsis, non-immunocompromised, few comorbidities, CT-confirmed inpatients, do not need antibiotics. Outpatient therapy has not been studied sufficiently.
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Complicated Diverticulitis
D. Complicated: Diverticular inflammation + abscess, stricture, obstruction, fistula or perforation.
1. Admission required.
2. Phlegmon: Inflammation and infection of tissue without abscess. Can be percutaneously drained.
3. Abscesses4. Perforation has high mortality rate. Needs IVF
1. Admission required.
2. Phlegmon: Inflammation and infection of tissue without abscess. Can be percutaneously drained.
3. Abscesses
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picking a door
VII. Disposition & Follow-Up
A. Discharge: Uncomplicated.
B. Admit: Intractable N/V, comorbidities, elderly, immunocompromised, persistent pain, chronic steroids. Complicated diverticulitis. Failed outpatient therapy (Symptoms or worsening radiographic findings within 6 weeks of initial presentation).
A. Discharge: Uncomplicated.
B. Admit: Intractable N/V, comorbidities, elderly, immunocompromised, persistent pain, chronic steroids. Complicated diverticulitis. Failed outpatient therapy (Symptoms or worsening radiographic findings within 6 weeks of initial presentation).
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What was the patient's outcome?
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References
- Tintinalli’s Chapter 82
- EM Lit of Note (http://www.emlitofnote.com/2015/12/the-slow-demise-of-antibiotics-for.html)
- American Gastroenterological Association Institute Guideline for the Management of Acute Diverticulitis (https://www.gastro.org/guidelines/Diverticulitis_Guideline_Final.pdf)
- Chabok A et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012; 99(4): 532-9. PMID: 22290281
- Biondo S et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg. 2014 Jan;259(1):38-44. PMID: 23732265
- Ma & Mateer’s Emergency Ultrasound Chapter 11
- Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD009092. DOI: 10.1002/14651858.CD009092.pub2.
- McNamara MM, Lalani T, Camacho MA, Carucci LR, Cash BD, Feig BW, Fowler KJ, Katz DS, Kim DH, Smith MP, Tulchinsky M, Yaghmai V, Yee J, Rosen MP, Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® left lower quadrant pain -- suspected diverticulitis [online publication]. Reston (VA): American College of Radiology (ACR); 2014. 7 p.
- AJR Am J Roentgenol. 1998 Jun;170(6):1445-9. Helical CT with only colonic contrast material for diagnosing diverticulitis: prospective evaluation of 150 patients. Rao PM1, Rhea JT, Novelline RA, Dobbins JM, Lawrason JN, Sacknoff R, Stuk JL.
- Radiology. 2005 Oct;237(1):189-96. Epub 2005 Aug 26. Suspected acute colon diverticulitis: imaging with low-dose unenhanced multi-detector row CT. Tack D1, Bohy P, Perlot I, De Maertelaer V, Alkeilani O, Sourtzis S, Gevenois PA.
- Dynamed: Diverticulitis.
