A urinalysis is useful for ruling out urinary tract infection, and a human chorionic gonadotropin urine test should be considered in premenopausal women to exclude pregnancy, particularly if antibiotics, imaging, or surgery is being considered. During the rectal examination, stool should be obtained for a fecal occult blood test to exclude occult gastrointestinal bleeding.
Measurement of C-reactive protein CRP should be considered. When the patient has left lower quadrant tenderness and a CRP level greater than 50 mg per L Also, in a series of patients of whom 35 percent had a perforation , only about 20 percent with a CRP level less than 50 mg per L had a perforation, compared with 69 percent with a CRP level greater than mg per L 1, Imaging is not necessary in most patients with mild symptoms.
Abdominal radiography may be helpful in patients with suspected perforation of a diverticulum, because it may demonstrate free air. Computed tomography CT , ultrasonography, and magnetic resonance imaging MRI are useful in selected patients to establish the diagnosis and the extent and severity of disease, and to exclude complications. Table 3 lists the accuracy of CT findings for the diagnosis of acute diverticulitis. Information from reference Computed tomography with oral contrast media showing changes characteristic of diverticulitis.
A Sigmoid diverticula with and without contrast media arrows , with associated thickening of bowel wall. B Extensive segment sigmoid diverticulitis arrows demonstrating multiple diverticula with pericolonic inflammation. Ultrasonography has good diagnostic accuracy for diverticulitis compared with CT; however, it is inferior to CT for estimating the extent of large abscesses and for evaluating for free air. MRI has good diagnostic accuracy.
However, MRI takes significantly longer than CT and may not be acceptable in critically ill patients. Colonoscopy is contraindicated in acute diverticulitis, but historically was recommended to be performed four to six weeks after resolution of acute diverticulitis to confirm the diagnosis and to exclude other causes e.
The decision to hospitalize a patient with uncomplicated diverticulitis depends on several factors, including the patient's ability to tolerate oral intake, severity of illness, comorbidities, and outpatient support systems. Inpatient management includes no food or drink by mouth, intravenous fluid resuscitation normal saline or lactated Ringer solution , and intravenous antibiotics. The usual practice in the United States for the treatment of diverticulitis includes broad-spectrum antibiotics against gram-negative rods and anaerobic bacteria Table 4.
A study randomized patients to antibiotics or placebo and found that antibiotic therapy for uncomplicated diverticulitis did not accelerate recovery, prevent complications, or prevent recurrence. Not recommended in mild, uncomplicated diverticulitis; recent trials suggest that taking no antibiotics is an option with appropriate follow-up 23 , Ciprofloxacin Cipro , mg orally every 12 hours, or levofloxacin Levaquin , mg orally every 24 hours, plus metronidazole Flagyl , mg orally every six hours.
Ciprofloxacin, mg IV every 12 hours, or levofloxacin, mg IV every 24 hours, plus metronidazole, mg IV every six hours or1 g IV every 12 hours. Ampicillin, 2 g IV every six hours, plus metronidazole, mg IV every six hours, plus ciprofloxacin, mg IV every 12 hours, or levofloxacin, mg IV every 24 hours.
Ampicillin, 2 g IV every six hours, plus metronidazole, mg IV every six hours, plus amikacin, gentamicin, or tobramycin. Information from references 22 through Patients with a localized abscess may be candidates for CT-guided percutaneous drainage, a procedure that does not increase the risk of recurrent diverticulitis. It should be used to stratify a patient's risk before surgery Table 5. Cloudy, purulent.
Br J Surg. Risk factors for diverticulitis include use of nonsteroidal anti-inflammatory drugs, increasing age, obesity, and a sedentary lifestyle. Patients who present with symptoms consistent with recurrent diverticulitis warrant a complete evaluation. Studies have shown recurrence rates of diverticulitis from 9 to 36 percent. In a large retrospective study involving 3, patients treated for diverticulitis with a mean follow-up of nine years, 9 percent had one recurrence and 3 percent had more than one recurrence after initial nonoperative management.
A retrospective study analyzing consecutive patients with diverticulitis found the five-year recurrence rate was 36 percent, with 3. Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, and, in persons with a body mass index of 30 kg per m 2 or higher, weight loss. Data Sources: A PubMed search was completed in Clinical Queries using the key terms diverticulitis, diverticulosis, diverticular disease, pathogenesis, diagnosis, and treatment.
The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Search date: April 15, Already a member or subscriber?
Log in. Interested in AAFP membership? Learn more. Reprints are not available from the authors. Acute diverticulitis. N Engl J Med. Diagnosis and management of diverticular disease of the colon in adults.
Am J Gastroenterol. The burden of selected digestive diseases in the United States. Diverticulitis in the United States: — changing patterns of disease and treatment.
Ann Surg. Cyclical increase in diverticulitis during the summer months. Arch Surg. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. The genetic influence on diverticular disease — a twin study. Aliment Pharmacol Ther. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department.
Acute left colonic diverticulitis: a prospective analysis of consecutive cases. Rebound tenderness test. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol. Diagnostic imaging for diverticulitis. J Clin Gastroenterol. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis.
Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. World J Surg. Frequency, sensitivity, and specificity of individual signs of diverticulitis on thin-section helical CT with colonic contrast material: experience with cases.
Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Routine colonoscopy following acute uncomplicated diverticulitis. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Although access to this website is not restricted, the information found here is intended for use by medical providers.
Patients should address specific medical concerns with their physicians. Toggle navigation. Infectious Disease Chapter. From Related Chapters. See Also Page Contents Diverticulosis. Page Contents Management: Approach Indications for outpatient management Uncomplicated Diverticulitis with mild pain or well controlled on Oral Analgesic s Stable clinically without signs of peritonitis Tolerating oral fluids Exercise caution in discharging patients at higher risk of failed outpatient management Abdominal free fluid on imaging esp.
CT Abdomen for most patients Diagnosis unclear Not classic Left Lower Quadrant Abdominal Pain with fever Other diagnoses are of similar likelihood Moderate to severe symptoms Inability to tolerate oral fluids Peritoneal signs Failure to improve in days. Course Improves on antibiotics within 48 to 72 hours. Follow-up Colonoscopy Do not perform in acute Diverticulitis Risk of bowel perforation Obtain 6 weeks after complicated Diverticulitis episode May not be needed in uncomplicated first-episode empirically treated Diverticulitis May also not be needed if last Colonoscopy within last years Consider also if approaching routine screening or if findings suggest other indication lau Dis Colon Rectum 54 10 : [PubMed] Westwood Br J Surg 98 11 : [PubMed] Findings Define extent of Diverticulosis Evaluate for Colon Cancer Barium Enema may be used as alternative option Surgical indications Recurrent uncomplicated Diverticulitis requiring hospitalization following third episode.
Diverticular disease: epidemiology and management. Can J Gastroenterol. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.
Clin Gastroenterol Hepatol. Diverticulitis in the United States: — changing patterns of disease and treatment. Ann Surg. Tursi A. Advances in the management of colonic diverticulitis.
Diverticular disease: a therapeutic overview. World J Gastrointest Pharmacol Ther. The feasibility and risk of early colonoscopy in acute diverticulitis: a prospective controlled study. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment? Colorectal Dis. Outpatient treatment of acute diverticulitis: rates and predictors of failure.
Management of uncomplicated acute diverticulitis: results of a survey. Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis. Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis.
Tech Coloproctol. Outpatient treatment for acute uncomplicated diverticulitis. Eur J Gastroenterol Hepatol. Outpatients versus hospitalisation management for uncomplicated diverticulitis: a prospective, multicenter randomised clinical trial DIVER Trial Ann Surg. Outpatient treatment of uncomplicated acute diverticulitis: impact on healthcare costs. Cir Esp. Mild colonic diverticulitis can be treated without antibiotics. A case-control study. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.
Br J Surg. Diagnosis and management of diverticular disease of the colon in adults. Am J Gastroenterol. Effectiveness of traditional Japanese herbal Kampo medicine, daiobotampito, in combination with antibiotic therapy in the treatment of acute diverticulitis: a preliminary study. Evid Based Complement Alternat Med. Chinese Herbal Medicine Formulas and Strategies. A high-fiber diet does not protect against asymptomatic diverticulosis.
A systematic review of high-fibre dietary therapy in diverticular disease. Nut, corn, and popcorn consumption and the incidence of diverticular disease. One year intermittent rifaximin plus fibre supplementation versus. Fibre supplementation alone to prevent recurrence of diverticulitis: a proof-of-concept study. Dig Liver Dis. Cyclic antibiotic therapy for diverticular disease: a critical reappraisal.
J Gastrointest Liver Dis. Treatment of diverticular disease of the colon and prevention of acute diverticulitis: a systematic review. Scarpignato C, Pelosini I. Experimental and clinical pharmacology of rifaximin, a gastrointestinal selective antibiotic. Stocchi L. Current indications and role of surgery in the management of sigmoid diverticulitis. World J Gastroenterol. Persistent symptoms after elective sigmoid resection for diverticulitis.
Patterns of recurrence in patients with acute diverticulitis. Multicentre observational study of the natural history of left-sided acute diverticulitis. Randomised clinical trial: mesalazine Salofalk granules for uncomplicated diverticular disease of the colon — a placebo-controlled study. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol.
Intermittent treatment with mesalazine in the prevention of recurrence of diverticulitis: a randomised multicentre pilot double-blind placebo-controlled study of month duration. Double-blind, randomized, placebo-controlled, multicenter trial of mesalamine for the prevention of recurrence of diverticulitis.
Prophylactic effects of mesalamine in diverticular disease; Abstract 13 presented at the Falk Symposium ; September 2—3, ; Cologne, Germany. Probiotics: effects on immunity. Am J Clin Nutr. Long-term treatment with rifaximin and lactobacilli in post-diverticulitic stenoses of the colon.
Eur Rev Med Pharmacol Sci. Acute recurrent diverticulitis is prevented by oral administration of a polybacterial lysate suspension. Minerva Gastroenterol Dietol. Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis — a prospective randomized study.
Microencapsulated sodium butyrate reduces the frequency of abdominal pain in patients with irritable bowel syndrome. Int J Cancer. Topical butyrate improves efficacy of 5-ASA in refractory distal ulcerative colitis: results of a multicentre trial.
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