Diverticulitis Diagnosis and Management

Clinical Presentation

• The American Gastroenterological Association notes that abdominal pain in the left lower quadrant is the most common presenting symptom of diverticulitis, often accompanied by fever, change in bowel habits, nausea, and elevated inflammatory markers such as white blood cell count and C-reactive protein 1, 2
• Abdominal tenderness on examination, typically localized to the left lower quadrant, is a common finding in patients with diverticulitis 3, 1

Diagnostic Approach

• The American College of Gastroenterology recommends CT scan of the abdomen and pelvis with oral and intravenous contrast as the gold standard for diagnosis of diverticulitis, with a sensitivity and specificity of 95% 1
• Abdominal ultrasonography is an alternative diagnostic method that avoids contrast and radiation exposure but is operator-dependent 1, 3

Classification of Diverticulitis

Uncomplicated Diverticulitis

• Uncomplicated diverticulitis involves thickening of the colon wall and peri-colonic inflammatory changes, with infection limited to the colon without extension to the peritoneum 1, 3

Complicated Diverticulitis

• Complicated diverticulitis is characterized by the presence of abscess, peritonitis, obstruction, stricture, and/or fistula, with the most common complication being phlegmon or abscess, followed by peritonitis, obstruction, stricture, and fistula 1, 2
• Only about 12% of patients present with complicated disease 1

Treatment Options

For Uncomplicated Diverticulitis

• The World Journal of Emergency Surgery suggests that conservative management without antibiotics is recommended for most patients with uncomplicated diverticulitis, with pain management primarily using acetaminophen 5
• Selective use of antibiotics is recommended for patients with comorbidities, frailty, immunocompromised status, or those older than 80 years 5, 6

For Complicated Diverticulitis

• Intravenous antibiotics, such as ceftriaxone plus metronidazole or piperacillin-tazobactam, are recommended for complicated diverticulitis 5
• Percutaneous drainage is recommended for abscesses ≥ 3-4 cm 5
• Surgical intervention is necessary for failed percutaneous drainage, generalized peritonitis, fistula formation, obstruction, or stricture 3, 5

Follow-up Care

• The American Gastroenterological Association recommends colonoscopy 6-8 weeks after resolution of symptoms for patients with complicated diverticulitis, first episode of uncomplicated diverticulitis, or if high-quality colonoscopy was not performed within the past year 1

Long-term Management

• Approximately 45% of patients report periodic abdominal pain at 1-year follow-up, and low to modest doses of tricyclic antidepressants may help with visceral hypersensitivity 6, 4
• Preventive measures include a high-fiber diet or fiber supplementation, regular exercise, smoking cessation, and weight loss for those with BMI ≥ 30 kg/m² 4