Management of Acute Diverticulitis – Short Notes

Acute diverticulitis must be suspected in patients suffering from lower abdominal pain commonly in the left lower quadrant), abdominal tenderness , and leukocytosis.

The diagnosis is generally established through} a computed tomography (CT) scan,  that additionally differentiates between complicated from uncomplicated disease.

Acute uncomplicated diverticulitis may  be  managed conservatively in the majority of patients (70 to 100 percent), irrespective of being  outpatient inpatient.

Acute complicated diverticulitis necessitates  treatment of colonic inflammation (diverticulitis) and the present complication

Treatment in hospital is indicated in:

CT reveals  complicated diverticulitis   characterized  by the presence of perforation, abscess, obstruction, or fistula.

CT reveals uncomplicated diverticulitis although the patient has one of these :

·        Sepsis

·        Immunosuppression

·        Fever

·        High leukocytosis

·        Severe abdominal pain or diffuse peritonitis

·        Comorbid illnesses

·        Intolerance of oral intake

·        Noncompliance

·        Failed outpatient treatment

·        Advanced age

Outpatient management:

Oral antibiotics for 7 to 10 days

like Ciprofloxacin plus metronidazole or Trimethoprim-sulfamethoxazole plus metronidazole

(covering the usual gut flora of Gram-negative bacilli and anaerobes, especially E. coli and B. fragilis)

Treatment of complications

Perforation

Frank perforation of the colon leads to diffuse peritonitis  while microperforation is only apparent by the presence of air bubbles along colon wall on computed tomography (CT) scan.

Microperforation perforation is treated with intravenous antibiotics

Abscess

Abscesses occur in up to half of patients

CT-guided  percutaneous drainage is indicated

Initially treated with intravenous antibiotics and percutaneous drainage

If  not reachable for percutaneous drainage or not improving , surgery is required

All successfully treated patients should be referred for elective surgery  

Obstruction

Surgical resection of the involved colonic segment is indicated to rule out cancer.

Fistula

A fistula can develop between the colon and bladder, vagina, uterus, adjacent bowel segments, and the abdominal wall.

resection of the affected segemnt is generally indicated

Intravenous antibiotics

Patients are kept  NPO  to allow  bowel rest

Alternatively a clear liquid diet according to the clinical status.

Intravenous fluid (eg, Ringer's lactate or normal saline)

Parenteral analgesics (eg, acetaminophen, ketorolac, or morphine)

Oral analgesics (eg, acetaminophen, ibuprofen, oxycodone)

clear liquids or complete bowel rest with intravenous hydration, depending upon the severity of symptoms.

Failure of inpatient medical treatment

Surgery is indicated at any time if the patient's condition deteriorates