Definition of diverticulitis
Diverticulitis is an inflammation or infection of one or more diverticula, which are small pouches or sacs formed from the intestinal lining.
This condition is generally caused by the stagnation of fecal waste or food in these diverticula, causing inflammation and sometimes a bacterial infection.
Diverticulitis usually occurs in the large intestine, specifically in the colon. It can cause symptoms such as abdominal pain, fever, nausea, vomiting, and changes in bowel habits.
In most cases, diverticulitis can be treated with antibiotics, dietary modification, and in some severe or recurrent cases, surgical intervention.
Complicated versus uncomplicated diverticulitis
Acute complications of colonic diverticulitis include:
- Abscess (common)
- Peritonitis (common)
- Obstruction (rare)
- Fistulization (rare)
The need for surgical intervention is much higher for complicated diverticulitis than for uncomplicated diverticulitis.
Decision on outpatient versus inpatient care
Based on the results of the history, physical examination, laboratory tests, and abdominal-pelvic CT scan, patients with acute colonic diverticulitis are directed towards inpatient or outpatient treatment. Inpatient care is indicated for patients with:
- Complicated diverticulitis (i.e., perforation, abscess, obstruction, or fistula).
- Risk factors for less favorable outpatient outcomes.
Patients without these risk factors have similar outcomes regardless of the care setting.
Treatment of diverticulitis
Computed Tomography (CT) or scanner : This is the most common and reliable method for diagnosing diverticulitis. The scanner allows visualization of the inflammation of the diverticula, abscesses, perforations, or other associated complications.
For patients for whom inpatient management of acute colonic diverticulitis is indicated, we suggest administering intravenous antibiotics (grade 2C).
Some of these patients have clear indications for antibiotic prescription (e.g., in case of an abscess) and there is no evidence that simple but severe diverticulitis can be treated without antibiotics.
The choice of antibiotic agents depends on the severity of the disease and risk factors for antibiotic resistance or treatment failure (e.g., advanced age, significant medical comorbidities, immunosuppression, travel to high-risk regions for bacterial resistance):
- Dubin-Johnson syndrome and Rotor syndrome: it is unnecessary to distinguish them clinically due to their benign nature.
- Mild to moderate symptoms without risk factors
- Severe symptoms and/or risk factors
- Nosocomial infection
Patients should initially be kept on complete digestive rest. Clinical response is generally observed after 2 to 3 days, at which point a liquid diet can be started and then improved based on tolerance. Patients who continue to improve are discharged with oral antibiotics to complete a total duration of 10 to 14 days of antibiotic treatment.
Patients who do not improve with inpatient treatment may require repeat imaging and/or surgical evaluation.
Treatment of complications
Patients with complicated diverticulitis should receive intravenous antibiotics and be treated according to the specifics of their complications. Diverticular abscesses ≥4 cm require percutaneous drainage if possible; smaller abscesses may respond to antibiotics alone. Sigmoid colectomy is the treatment of choice for perforations, obstructions, or fistulizations.
An isolated elevation of conjugated bilirubin is observed in two rare hereditary syndromes: Dubin-Johnson syndrome and Rotor syndrome, as well as other genetic bile transport disorders in children. Dubin-Johnson syndrome and Rotor syndrome should be suspected in patients with mild hyperbilirubinemia (with a directly reacting fraction of about 50 percent) in the absence of other abnormalities in standard liver biochemical tests.
Normal serum levels of alkaline phosphatase and gamma-glutamyltransferase help differentiate these conditions from disorders associated with bile duct obstruction. Differentiation between these syndromes is possible but not necessary at the clinical level due to their benign nature.
Source: UpToDate