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Colonic Diverticulitis

By Joel A. Baum, MD, Assistant Professor of Medicine, Chairman, Icahn School of Medicine at Mount Sinai ; Rafael Antonio Ching Companioni, MD, Icahn School of Medicine, Elmhurst Hospital Center

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Diverticulitis is inflammation and/or infection of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom is abdominal pain. Diagnosis is by CT. Treatment is with bowel rest, sometimes antibiotics, and occasionally surgery.

A colonic diverticulum is a saclike pouch of colonic mucosa and submucosa that protrudes through the muscular layer of the colon; because it does not contain all layers of the bowel, it is considered a pseudodiverticulum (see also Definition of Diverticular Disease). Many people have multiple colonic diverticula (diverticulosis). The incidence of diverticulosis rises with increasing age; it is present in three quarters of people > 80 yr.

Diverticula are usually asymptomatic but sometimes become inflamed (diverticulitis). A 2013 study reported that 4.3% of patients with documented diverticulosis developed diverticulitis over an 11-yr follow-up period (1).

Diverticulitis that is managed nonoperatively can recur as either an acute or chronic process. The risk of a recurrent acute episode is up to 39%, although reported rates vary widely (2). About half of second episodes of diverticulitis occur within 12 mo. In some patients, however, recurrence manifests as chronic, ongoing abdominal pain; this may develop after one or more acute episodes.

Risk references

  • 1. Shahedi K, Fuller G, Bolus R, et al: Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol11(12):1609–1613, 2013. doi: 10.1016/j.cgh.2013.06.020.

  • 2. Sallinen V, Mali J, Leppäniemi A, Mentula P: Assessment of risk for recurrent diverticulitis: A proposal of risk score for complicated recurrence. Medicine (Baltimore) 94(8):e557, 2015. doi:10.1097/MD.0000000000000557.

Etiology

The etiology and pathophysiology of diverticulitis is not fully understood and may vary among patients. It has long been thought that diverticulitis occurs when a micro or macro perforation develops in a diverticulum resulting in the release of intestinal bacteria and triggering inflammation. However, emerging data suggest that acute diverticulitis is more of an inflammatory than infectious process in some patients. Furthermore, cytomegalovirus may be a trigger of that inflammation; active viral replication has been found in affected colon tissue in over two thirds of patients with diverticulitis.

A 2017 study suggested a direct correlation between red meat consumption per week and the incidence of diverticulitis (3, 4). There is no association between consumption of nuts, seeds, corn, or popcorn and development of diverticulitis as was previously thought.

Etiology references

  • 3. Cao Y, Strate LL, Keeley BR, et al: Meat intake and risk of diverticulitis among men. Gut pii: gutjnl-2016-313082, 2017. doi: 10.1136/gutjnl-2016-313082.

  • 4. Strate LL, Keeley BR, Cao Y, et al: Western dietary pattern increases, and prudent dietary pattern decreases, risk of incident diverticulitis in a prospective cohort study. Gastroenterology 152(5):1023–1030.e2, 2017. doi: 10.1053/j.gastro.2016.12.038.

Classification

Diverticulitis can be classified as

Complications can develop following perforation of an inflamed diverticulum.

About 15% of patients with complicated diverticulitis have a pericolic or intramesenteric abscess.

Classification of Complicated Diverticulitis

Stage

Hinchey Classification

Modified Hinchey Classification

I

Pericolic abscess or phlegmon

Pericolic abscess

II

Pelvic, intra-abdominal, or retroperitoneal abscess

IIa

Distant abscess that can be drained percutaneously

IIb

Complex abscess with fistula

III

Generalized purulent peritonitis

Generalized purulent peritonitis

IV

Generalized fecal peritonitis

Fecal peritonitis

Adapted from Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA: Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 27(2):207–214, 2012. doi:10.1007/s00384-011-1314-5.

Symptoms and Signs

Patients have left lower quadrant abdominal pain and tenderness and often have a palpable sigmoid; pain is occasionally suprapubic. However, Asians with diverticulitis often present with right-sided pain due to right colon involvement. The pain can be accompanied by nausea, vomiting, fever, and sometimes even urinary symptoms as a result of bladder irritation. Peritoneal signs (eg, rebound or guarding) may be present, particularly with abscess or free perforation. Fistula may manifest as pneumaturia, feculent vaginal discharge, or a cutaneous or myofascial infection of the abdominal wall, perineum, or upper leg. Patients with bowel obstruction have nausea, vomiting, and abdominal distention. Bleeding is uncommon.

Recurrent episodes of acute diverticulitis manifest similar to initial episodes; they are not necessarily more severe.

Diagnosis

  • Abdominal and pelvic CT

  • Colonoscopy after resolution

Clinical suspicion is high in patients with known diverticulosis who present with characteristic abdominal symptoms. However, because other disorders (eg, appendicitis, colon or ovarian cancer, IBD) may cause similar symptoms, testing is required.

Diverticulitis is evaluated with CT of the abdomen and pelvis with water-soluble contrast given orally and rectally; IV contrast also is given when not contraindicated. However, findings in about 10% of patients cannot distinguish diverticulitis from colon cancer. MRI is an alternative for pregnant and young patients.

Colonoscopy is often recommended 1 to 3 mo after resolution of the episode to assess for cancer.

Treatment

  • Varies with severity

  • Liquid diet for mild disease; npo for more severe disease

  • Sometimes antibiotics

  • CT-guided percutaneous drainage of abscess

  • Sometimes surgery

A patient who is not very ill is treated at home with rest and a liquid diet. Symptoms usually subside rapidly.

Patients with more severe symptoms (eg, pain, fever, marked leukocytosis) should be hospitalized, as should patients taking prednisone (who are at higher risk of perforation and general peritonitis). Treatment is bed rest, npo, and IV fluids.

Antibiotics

Antibiotics were traditionally recommended for all cases of acute diverticulitis whether or not they were complicated. However, recent data suggest that antibiotics may not improve outcome in uncomplicated diverticulitis, therefore, selected patients with acute uncomplicated diverticulitis can be managed conservatively. (See also the American College of Gastroenterology guidelines on management of acute diverticulitis.)

If antibiotics are used, they should cover gram-negative rods and anaerobic bacteria.

Antibiotic regimens that can be used orally for outpatients for whom treatment is elected include 7 to 10 days of

  • Metronidazole (500 mg q 8 h) plus a fluoroquinolone (eg, ciprofloxacin 500 mg q 12 h)

  • Metronidazole (500 mg q 8 h) plus trimethoprim/sulfamethoxazole (800/160 mg q 12 h)

  • Amoxicillin (875 mg q 12 h) plus clavulanate (125 mg q 12 h)

  • Moxifloxacin (400 mg once/day for patients unable to take penicillins or metronidazole)

IV antibiotic regimens for hospitalized patients are selected based on many factors, including the severity of illness, risk of adverse outcome (eg, due to other illnesses, older age, immunosuppression), and likelihood of resistant organisms. Many regimens exist.

Small pericolic abscesses up to 2 to 3 cm in diameter often resolve with broad-spectrum antibiotics and bowel rest alone.

If response is satisfactory, the patient remains hospitalized until symptoms are relieved and a soft diet is resumed.

In patients with acute diverticulitis, the risk of recurrence is up to 50%.

Percutaneous drainage

CT-guided percutaneous drainage is becoming the standard of care for larger abscesses (over 2 to 3 cm in diameter). However, abscesses that are multiloculated, inaccessible, or not improving with drainage require surgical intervention.

Surgery

Surgery is required immediately for patients with free perforation or general peritonitis. Other indications for surgery include severe symptoms that do not respond to nonsurgical treatment within 3 to 5 days and increasing pain, tenderness, and fever. About 15 to 20% of people admitted with acute diverticulitis require surgery during that admission (5).

For uncomplicated diverticulitis, surgical resection was previously recommended based on the number of recurrences. Currently, the American Society of Colon and Rectal Surgeons (ASCRS) recommends a case-by-case evaluation rather than mandatory elective segmental colectomy after a second episode (6, 7, 8). Patients for whom recurrent attacks pose a higher risk of death or complications are typically considered candidates for surgery.

For complicated diverticulitis, elective segmental colectomy is recommended after one episode. For those whose symptoms resolved with antibiotics and/or percutaneous drainage, the surgery can be done electively at a later time, when a single rather than multi-stage procedure can be used.

The involved section of the colon is resected. The ends can be reanastomosed immediately in healthy patients without perforation, abscess, or significant inflammation. Other patients have a temporary colostomy with anastomosis carried out in a subsequent operation after inflammation resolves and their general condition improves.

Treatment references

Key Points

  • Diverticulitis is inflammation and/or infection of a diverticulum.

  • Inflammation remains localized in about 75% of patients; the remainder develop abscesses, peritonitis, bowel obstruction, or fistulas.

  • Diagnose using abdominal and pelvic CT with oral, rectal, and IV contrast; do colonoscopy 1 to 3 mo after the episode to look for cancer.

  • Management depends on severity but typically includes conservative management, often antibiotics, and sometimes percutaneous or surgical drainage, or surgical resection.

Segmental Colitis Associated With Diverticulosis (SCAD)

Segmental colitis associated with diverticular disease refers to chronic colonic inflammation affecting the interdiverticular mucosa. Diagnosis is by endoscopy. Treatment is symptomatic.

Segmental colitis associated with diverticulosis (SCAD) and chronic recurrent diverticulitis are terms used to describe chronic colonic inflammation attributed to diverticulosis. SCAD usually affects the interdiverticular mucosa and is usually present on the left side sparing the rectum and ascending colon.

The cause is unknown and may be multifactorial. Mucosal prolapse, fecal stasis, localized ischemia, alterations in the gut microbiota, and/or chronic inflammation may play a role. It is unclear how much the relationship between the diverticulosis and colitis is causal, due to a common underlying factor, or coincidental: the histologic characteristics contain similar features to that seen in inflammatory bowel disease (IBD), infectious colitis, and ischemic colitis. The prevalence of SCAD in people with diverticulosis is very low (1%). SCAD usually affects males > 60 yr of age.

Symptoms of SCAD include hematochezia, abdominal pain, and diarrhea.

The diagnosis is suggested when endoscopy reveals erythematous, friable, and granular mucosa with either a diffuse or patchy distribution involving the interdiverticular mucosa.

Treatment of SCAD is symptomatic. Oral preparations of 5-aminosalicylic acid (5-ASA) have been used but, to date, high-quality randomized clinical trials have not been done.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • CILOXAN, CIPRO
  • No US brand name
  • AMOXIL
  • RAYOS
  • AVELOX
  • FLAGYL

* This is the Professional Version. *