Diverticulitis

Introduction

Diverticulitis is a common cause of presentation to the ED. Diverticulitis occurs when one or more diverticula (outpouches of colonic mucosa through areas of weakness in musculature in the bowel wall) become inflamed.

Faecal material or undigested food is thought to collect in a diverticulum causing obstruction followed by secondary infection.

Diverticular disease is usually seen in those > 50 years and it’s incidence increases with age.

Clinical Features

 

Symptoms

Pain

  • Typically constant in nature as opposed to colicky

  • Most common in the left iliac fossa, but can occur anywhere

GIT symptoms

  • Recent alterations in bowel habit - diarrhoea or constipation

  • Pr bleeding is often seen

Signs

Signs of sepsis

  • Fever

  • Tachycardia

  • Hypotension

  • Tachycardia

Peritonism

  • Guarding

    • voluntary

    • involuntary

  • Rebound tenderness

  • Generalised rigidity should prompt concern for possible perforation

Frank blood on PR exam

Complications

  • Abscess formation

  • Perforation

  • Fistulae

  • Obstruction

  • Critical PR bleed

Differential Diagnosis

 

Bowel

  • Appendicitis

  • Inflammatory bowel disease

  • Infectious colitis

  • Ischaemic colitis

  • Malignancy

  • Inguinal hernia

  • Bowel obstruction

Renal Pathology

  • Pyelonephritis

  • Ureteric colic

Reproductive

  • Referred testicular pain

  • Ovarian pathology

  • Uterine fibroids

Clinical Investigation

 

Bedside

  • Urinalysis aids in excluding urinary pathology

  • Urinary beta HCG should be performed in ALL women of childbearing potential

  • Venous blood glass, high lactate and low pH are both concerning

  • ECG - ischaemic colitis is more common in patients with atrial fibrillation

 
 
 

Colonoscopy

Should be arranged after full recovery from the first acute episode to confirm the presence of diverticular disease

Laboratory

FBC

  • High WCC - suggestive inflammation

  • Low Hb - in severe or chronic pr bleeding

CRP - when elevated suggests active inflammation

U&E - looking for evidence of AKI if concurrant sepsis or dehydration

LFT’s & amylase - help rule out other causes

Group & hold - may be indicated if significant bleeding

Radiology

Erect cxr

  • look for free air under the diaphragm which indicates perforation

Abdominal x-ray to rule out bowel obstruction

Ct abdomen with contrast is the investigation of choice looking for;

  • Presence of diverticulae

  • Colonic wall thickening

  • Enhancement of the colonic wall

  • Adjacent fat stranding

  • Evidence of complications

 

Treatment & Disposition

Initial resuscitation

  • Iv access

  • Iv fluids as clinically indicated

Symptomatic treatment

  • Analgesia

  • Anti-emetics if indicated

Specific treatment

  • Keep nil by mouth pending decision regarding operative management

  • Iv antibiotics as per local anti-microbial guidelines. A reasonable regimen would be

    • Iv Co-amoxiclav 1.2g TDS

    • Iv Metronidazole 500mg TDS

  • Surgical treatment may be required for certain complications

Disposition

  • Mild cases can be treated as an outpatient with po antibiotics

  • Moderate / Severe cases should be referred to the surgical team on call for hospital admission as should mild cases that haven’t responded to oral antibiotics

References

1.    Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 23115

2.    St James’s Hospital prescribers capsule. Empiric antimicrobial guidelines

This blog was written by Dr. Deirdre Glynn and was last updated in October 2020

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