Diverticulitis

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Retention of undigested food and bacteria in diverticulum leads to fecalith formation with obstruction  which compromise diverticulum’s blood supply, infection, perforation 

Uncomplicated: microperforation leading to localized infection 

Complicated: macroperforation leading to abscess, peritonitis, fistula, obstruction 

Clinical presentation 

• LLQ abdominal pain, fever, nausea, vomiting, constipation or diarrhea
• Physical findings range from LLQ tenderness and/or palpable mass to peritoneal signs and septic shock
• Differential  diagnosis  includes  IBD,  infectious  colitis,  PID,  tubal  pregnancy,  cystitis, colorectal cancer

Investigations 

• Plain abdominal radiographs to rule out free air, ileus or obstruction
• Abdominal CT scan with contrast, to assess complicated disease (abscess, fistula)
• Colonoscopy contraindicated acutely as increases the risk of perforation; do 6–8 weeks after to rule out neoplasm

Pharmacological Treatment   

Mild: outpatient indicated if patient has little comorbidity and can tolerate oral intake 

A: amoxicillin + clavulanate FDC (PO) 625mg 12hourly daily for 7–10days 

AND 

A: metronidazole (PO) 400mg 8hourly for 7–10days 

AND 

Liquid diet until clinical improvement 

Alternatively 

A: ciprofloxacin (PO) 500mg 12hourly daily for 7–10days 

OR 

A: metronidazole 400mg (PO) 8hourly for 7–10days 

AND 

Liquid diet until clinical improvement 

For severe cases 

B: ceftriaxone (IV) 1-2g 24hourly for 7-10days 

OR  

S: piperacillin + tazobactam (IV) 4.5gm 6-8hourly 7-10days (for severe/complicated cases) 

OR  

S: meropenem (IV) 1gm 8hourly 7-10days 

AND 

B: metronidazole (IV) 500mg 8hourly for 7-10days 

Note:

• Abscesses >4 cm should be drained percutaneously or surgically.
• Surgery: if progressions despite medical treatment, undrainable abscess, free perforation. After source control, 4days antibiotics may be enough.
• Resection for recurrent bouts of diverticulitis on a case-by-case basis.