Diverticulitis - Quick Consult
Last Updated / Reviewed: 4/5/2021

Definition
Key History
Key Physical Exam
Risk Factors for Diverticulitis
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment

Definition

Diverticulitis is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed, occurring in 4% of patients with diverticulosis.

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Key History

  • Most common clinical presentation: LLQ pain, fever and leukocytosis
  • History of diverticulosis
  • History of similar pain
  • Pain is severe, may radiate to back, worsens with bowel movement
  • Fever with chills as severity increases
  • Anorexia
  • Nausea/Vomiting
  • Constipation or diarrhea
  • Dysuria or urgency may be present
  • Heme positive stool in 25%
  • Enterocutaneous or enterovaginal or perirectal fistulae may be the initial presentation.
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Key Physical Exam

  • Rebound tenderness
  • Palpable mass LLQ
  • Abdomen distended and typanitic
  • Bowel sounds decreased or increased
  • Fecaluria (urine mixed with feces) with colovesical fistula
  • Rectal exam – may be tender, mass may be present in cul-de-sac
  • Heme positive stool in 25%
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Risk Factors for Diverticulitis

  • History of Diverticulosis
  • Age > 40
  • Poor fiber intake
  • Lack of exercise
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Differential Diagnosis

Gastrointestinal Genitourinary Cardiovascular
  • Appendiceal neoplasm
  • Abdominal aortic aneurysm
  • Appendicitis
  • Cecal diverticulitis
  • Cholecystitis
  • Cholelithiasis
  • Constipation
  • Crohn's disease
  • Gastroenteritis
  • GERD
  • GI Bleed
  • Hepatitis
  • Intestinal obstruction
  • Intussusception
  • Irritable bowel syndrome
  • Meckel’s diverticulitis
  • Mesenteric adenitis
  • Mesenteric ischemia
  • Omental torsion
  • Pancreatitis
  • Peptic ulcer disease
  • Perforated ulcer
  • Peritonitis
  • Small bowel obstruction
  • Typhlitis
  • Nephritis
  • Prostatitis
  • Pyelonephritis
  • Renal colic
  • Testicular torsion
  • Ureterolithiasis
  • Urinary tract infection
  • Dysmenorrhea
  • Ectopic pregnancy
  • Endometriosis
  • Menorrhagia
  • Ovarian torsion
  • Ovarian cancer
  • PID
  • Ruptured cyst (Mittelschmerz)
  • Tubal ovarian abscess
  • Twisted ovarian cyst
Other
  • Diabetes ketoacidosis
  • Hemolytic uremic syndromes
  • Herpes zoster
  • Henoch-Schoenlein purpura
  • Pneumonia
  • Sickle Cell Crisis
  • Streptococcal pharyngitis

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Diagnostic Testing

Text / literature information and recommendations include:
  1. CBC, LFTs, renal panel and UA results are not diagnostic for diverticulitis, but may help exclude other disorders.
  2. CT abdomen and pelvis with IV contrast is the imaging test of choice, with 98% accuracy and the ability to demonstrate other causes of LLQ pain.
  3. Graded compression transabdominal ultrasound is operator dependent, limited by obese body habitus, and has lower sensitivity and specificity than CT.
  4. Plain film radiographs are usually not appropriate.
  5. Pelvic exam is recommended for women to rule out pelvic pathology.
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Clinical Risk and Safety Pearls

  • Left-sided diverticulitis is common in Western countries. Right-sided diverticulitis is common in Asian countries.
  • Diverticulitis can occur in patients under 40.
  • Approximately 15% of patients with diverticulitis will have a complication, such as abscess, perforation, fistula or colonic obstruction.
  • Most patients with acute uncomplicated diverticulitis can be treated with conservative therapy, including antibiotics (selectively) and bowel rest.
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Treatment

Common text / literature recommendations include:
  1. Surgical Consult
  2. IV antibiotics – broad spectrum to cover gram-negative aerobes and anaerobes – Ampicillin/sulbactam OR imipenem OR Metronidazole AND Cipro
  3. IV hydration
  4. NPO
  5. Type and cross match if GI bleeding
  6. Bowel rest
  7. Mild cases may be treated with outpatient oral antibiotics – Cipro and flagyl or amoxicillin-clavulanate and a clear liquid diet. Patients sent home should be advised to call or come back with increasing pain, fever, or inability to tolerate fluids or no clinical improvement after 2 to 3 days.
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  1. Expert Panel on Gastrointestinal Imaging; Galgano SJ, McNamara MM, Peterson CM, et al. ACR Appropriateness Criteria®: Left Lower Quadrant Pain-Suspected Diverticulitis. J Am Coll Radiol. 2019;16(5S):S141-S149.
  2. Graham A. Chapter 82: Diverticulitis. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016.
  3. Rezapour M, Ali S, Stollman N. Diverticular disease: An update on pathogenesis and management. Gut Liver. 2018;12(2):125-132.
  4. Sartelli M, Catena F, Ansaloni L, et al. WSES Guidelines for the management of the acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg. 2016;11:37.
  5. Stollman N, Smalley W, Hirano I; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015;149(7):1944-1949.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.

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