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Diverticulitis
Treatment depends on the severity
of disease and presence of complications
BY Brinderjit Kaila, MD and Eldon
Shaffer, MD
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Carol C., 65 years old, presents to
the emergency department with left lower quadrant pain (LLQ). This
has been ongoing for three days, with progressive worsening but no
radiation of the pain. She has some nausea, and loose brown stool
without blood or melena. There are no fever, chills, vomiting, urinary
symptoms, upper respiratory tract complaints or central nervous system
disorders. Other than the LLQ pain, there are no manifestations of
inflammatory bowel disease (IBD). The patient has no history of sick
contacts, travel, antibiotic use or suspicious food ingestion. She
lives independently with her 66-year-old husband.
Presentation
History
- hypertension
- osteoarthritis
- no family history of IBD or colorectal
cancer
Physical examination
- patient obviously uncomfortable
- heart rate: 80 beats/minute
- blood pressure: 140/85 mm Hg
- respiratory rate: 12 breaths/minute
- temperature: 37.5°C
- abdominal exam: firm and distended;
normal bowel sounds; tenderness to the LLQ pain; no peritoneal
signs
- no hepatosplenomegaly
Investigations
- hematology: hemoglobin 140 g/L, white
blood cell count 12.0 x 109/L,
platelets 220 x 109/L
- chemistry: sodium 140 mmol/L, potassium
4.0 mmol/L, urea 6.0 mmol/L, creatinine 92 µmol/L
- urine analysis: normal
- microbiology: urine culture negative,
blood culture negative
- abdominal x-ray: no free air or obstruction
- abdominal computed tomography
(CT) scan:
- multiple left-sided diverticula
- inflammation of the perisigmoid
fat
- thickening of the bowel wall
in sigmoid region
- findings consistent with diverticulitis
With intravenous fluids for the next
24 hours, the patient's pain resolves. She's discharged with
ciprofloxacin 500 mg twice a day and metronidazole 500 mg
every 6 hours for seven days.
New
flare-up
Six months later, Carol C. returns with worsening LLQ pain
radiating to her back, 38.8°C fever and diarrhea (several
semi-formed, non-bloody stools). Her blood pressure has dropped
to 115/65 mm Hg. The examination indicates generalized abdominal
peritonitis. An abdominal x-ray and CT scan report perforation
of the sigmoid colon. After an urgent surgical consultation,
Mrs. C. is administered intravenous (IV) cefotaxime 2 g every
8 hrs and metronidazole 50 mg IV every 6 hrs. During the emergency
laparotomy that follows, surgeons remove 10 cm of the sigmoid
colon, leaving her with a diverting colostomy and rectal stump.
After two weeks, she's discharged home, with an outpatient
colonoscopy scheduled at 6-8 weeks to exclude colorectal malignancy
and a plan for reanastomosis three months later.
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Making the case
Diverticular disease encompasses the spectrum from asymptomatic
diverticula (sac-like protrusions of mucosa through the colonic
wall) to diverticulosis (several diverticula) to diverticulitis
— diverticula that are inflamed, with microperforations that
can lead to local abscesses and fistula. Diverticulosis is age-dependent.
The prevalence is less than 5% at age 40 and rises to 65-80% at
ages 85 and over.1 Females predominate
slightly.
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