Stages Of Diverticulitis
Stage I Small, confined pericolic abscess Stage II Distant abscess (retroperitoneal or pelvic)
Stage III Generalized suppurative peritonitis from rupture of abscess (noncommu-
nicating with bowel lumen) Stage IV Fecal peritonitis caused by a free communicating perforation diverticular neck, setting up for more inflammation and diminished venous outflow, as well as bacterial overgrowth, which ultimately leads to abrasion and perforation of the thin diverticular wall. It is classified into four stages according to the extent of the inflammation and perforation (Table 26-1).
Diagnosis
Patients usually present with visceral pain that localizes later to the left lower quadrant and that is associated with fever, nausea, vomiting, or constipation. A right lower quadrant presentation would not exclude this diagnosis because ascending colon or cecal diverticulitis can occur. If a colovesical fistula is present, the patient may present with pneumaturia or fecaluria (a virtually pathognomic finding). On examination, the patient may have localized left lower quadrant tenderness or more diffuse abdominal tenderness with peritoneal irritation signs, such as guarding or rebound tenderness. The differential diagnosis includes painful diverticular disease without diverticulitis, acute appendicitis, Crohn disease, colon carcinoma, ischemic colitis, irritable bowel syndrome, and gynecologic disorders such as ruptured ovarian cyst, endometriosis, ectopic pregnancy, and pelvic inflammatory disease.
Plain film radiographs, including abdominal erect and supine films with a chest x-ray, are routinely performed but usually are not diagnostic. They help in identifying patients with pneumoperitoneum and assessing their cardiopulmonary status, especially in patients with other comorbid conditions. Contrast enemas are contraindicated for fear of perforation and spillage of contrast into the abdominal cavity, a catastrophic complication. Endoscopy is also relatively contraindicated in the acute phase and usually is reserved for use at least 6 weeks after resolution of the attack and then is performed primarily to exclude colonic-neoplasia. CT scan typically is the preferred modality of choice for diagnosing diverticulitis if there is a high pretest probability from clinical suspicion. Findings consistent with diverticulitis include the presence of pericolic fat stranding, thickening of the bowel wall to >4 mm, or the finding of a peridiver-ticular abscess.
Therapy
Factors that advocate for inpatient therapy include the need for narcotics to control pain, presence of peritoneal signs, presence of comorbid illnesses, inability to tolerate oral liquids, or presence of any of the complications that may potentially require surgical intervention (abscess or peritonitis). Indications for emergent surgical intervention include generalized peritonitis, uncontrolled sepsis, perforation, and clinical deterioration. In the absence of acute complications, elective resection is undertaken later in cases of complications including fistula formation and when there are recurrent episodes of diverticulitis.
Individuals treated as outpatients should be placed on a broad-spectrum antibiotic regimen that covers abdominal gram-negative rods and anaerobes, such as trimethoprim/sulfamethoxazole, or ciprofloxacin with metronidazole or clindamycin with gentamicin. Patients should be placed on a clear liquid diet and undergo close follow-up.
The treatment priorities in hospitalized patients are intravenous hydration, correction of electrolyte imbalances, and bowel rest (nothing by mouth). Some recommended broad-spectrum intravenous antibiotic regimens include standard triple therapy (ampicillin, an aminoglycoside, and metronidazole) and p-lactamase inhibitor combinations (ampicillin-sulbactam or ticarcillin-clavulanate). among others. More empiric agents, such as imipenem or meropenem. usually are reserved for more severe and complicated cases. Pain, fever, and leukocytosis are expected to diminish with appropriate management in the first few days of treatment, at which point the dietary intake can be advanced gradually. Further imaging may be indicated to identify complications (Table 26-2) such as abscess, stricture, or obstruction in the patient with persistent fever or pain.
Table 26-2
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