Figure 54.1 Algorithm for the workup and treatment of acute diverticulitis.
Peridiverticulitis
When ulceration or ischemia is not accompanied by free communication with the peritoneal cavity, penetration of mixed bacterial flora into the wall initiates peridiverticular infection.
Patients with localized peridiverticular disease usually complain of abdominal pain localized to the left lower quadrant. In some cases, however, a redundant sigmoid colon may have sufficient mobility to produce local symptoms in the right lower or right upper abdominal quadrant as well as in the midepigastrium. These patients are often febrile and have mild leukocytosis. However, they typically respond well to bowel rest, parenteral fluids, and antibiotic therapy. Nasogastric tube insertion is usually unnecessary unless obstructive signs and symptoms are present.
It is important that patients take nothing by mouth to abolish the gastrocolic reflex. Morphine sulfate should not be administered because it can increase intracolonic pressure. Most patients require a 3- to 5-day course of appropriate parenteral antimicrobials (Table 54.1). If they continue to improve, with normalization of the white blood cell (WBC) count, temperature, and abdominal examination, we discontinue their parenteral antibiotics and advance them to a regular diet that is devoid of poorly digestible foods (e.g., whole corn).
| Drug | Dosage | Frequency |
|---|---|---|
| Combination therapy | ||
| Aerobic coveragea | ||
| Amikacin Aztreonam Ceftriaxone Ciprofloxacin Gentamicin Tobramycin | 15–20 mg/kg/d 1–2 g 1–2 g 400 mg 5–7 mg/kg/d 5–7 mg/kg/d | q8–12h q6–8h 12–24h ql2h q8h q8h |
| Anaerobic coverageb | ||
| Clindamycin Metronidazole | 600–900 mg 500 mg | q8h q8–12h |
| AEROBIC–ANAEROBIC COVERAGE (SINGLE-DRUG THERAPY) | ||
| Ampicillin–sulbactam Cefotetan Cefoxitin Ertapenem Imipenem–cilastatin Meropenem Piperacillin–tazobactam Ticarcillin–clavulanate Tigecyline | 1.5–3 g 1–2 g 1–2 g 1 g 500 mg 1 g 3.375–4.5 g 3.1 g 100 mg (initial dose) then 50 mg | q6h q8–12h q6h q24h q6h q8h q6h q6h q12h |
Patients must be followed carefully after resolution of abdominal symptoms. If no disease other than diverticulosis is found on follow-up endoscopy, each patient should follow a fiber-supplemented diet with a generous consumption of fluids.
We do not recommend surgery after uncomplicated diverticulitis in otherwise healthy patients. Rather, we recommend medical therapy and the decision for elective surgery after resolution should be made on a case-by-case basis. Some factors which may influence the decision to proceed with elective colon resection include, frequency of episodes, age and immune status of the patient. Such resection can be performed by an open laparotomy technique or by laparoscopic technique if the equipment and expertise is available.
Although the medical approach rarely fails to control the signs and symptoms of peridiverticulitis, surgical resection may become necessary if the infection does not resolve with prolonged parenteral antibiotic therapy. Occasionally, a major complication such as liver abscess or bacteremia develops and requires colonic resection. However, patients with very limited symptoms and no signs of systemic sepsis may respond to oral regimens of antibiotics aimed at covering these colonic aerobes and anaerobes (Table 54.2).
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