Figure 54.1 Algorithm for the workup and treatment of acute diverticulitis.
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).
|AEROBIC–ANAEROBIC COVERAGE (SINGLE-DRUG THERAPY)|
100 mg (initial dose) then 50 mg
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).