diverticulitis
DIVERTICULITIS
Diverticulitis is the acute inflammation of the diverticulum or saclike protrusion from the wall of the intestines caused by injury and bacterial proliferation. 
Abdominal pain is usually localized to the left lower quadrant, is abrupt, steady, severe and worsens over time.
Other signs and symptoms are fever, anorexia, nausea, vomiting, and altered bowel movements especially constipation but may also present with diarrhea or tenesmus.

Diagnosis

Predisposing Factors

  • Right-sided diverticula is predominant in Asian populations, while left-sided disease is more common in Western populations
  • A diet that is low in fiber & high in fat & red meat
  • Incidence increases with age
    • The disease is rare in individuals <40 years old
  • Disease frequency is similar in both genders
  • Other factors which may predispose to diverticulitis are colonic motility disorders, colonic wall defects, ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) & ingestion of corticosteroids

History

  • A thorough clinical history must be obtained to help rule out other causes of abdominal pain

Physical Examination

  • A complete directed physical exam must be conducted including abdominal, rectal & pelvic exams
  • Abdominal findings:
    • Direct & rebound tenderness over the involved area is noted in cases of localized peritonitis
    • Generalized tenderness, involuntary guarding & decreased or absent bowel sounds are seen in generalized peritonitis
    • A mass is occasionally palpated at the site of inflammation & may be apparent on abdominal palpation, rectal or pelvic exam
    • Abdomen may be distended & tympanic on percussion
  • A rectal exam may help elicit tenderness, establish stool color & check for gastrointestinal bleeding

Laboratory Tests

  • Complete blood count (CBC)
    • Leukocytosis with or without a left shift indicates infection
    • Immunocompromised & elderly patients may have normal results
  • Liver function tests (LFTs), lipase, amylase
    • May help establish other causes of abdominal pain
  • Blood cultures
    • Perform prior to giving empiric antibiotic therapy
  • Urinalysis & urine cultures
    • Demonstrate urinary tract infection (UTI), which is most likely due to a colovesicular fistula

Imaging

If the clinical picture is clear, some experts suggest that a diagnosis of diverticulitis can be made on the basis of clinical criteria alone

Abdominal Computed Tomography (CT) Scan

  • There is an increasing trend toward using the CT scan as the imaging test of choice for the evaluation of acute diverticulitis
    • Sensitivity is reported at 79-99% with specificity at 72%
  • Criteria for diagnosis of diverticulitis include the following:
    • Colonic wall thickening
    • Pericolic fat infiltration
    • Pericolic or distant abscesses
    • Extraluminal air
  • Able to determine disease extent ie presence of abscesses, thus facilitating the decision of administering medical vs surgical therapy
  • May be employed in performing percutaneous drainage of abscesses
  • Able to show extracolonic diseases which may present with symptoms similar to those of diverticulitis eg tubo-ovarian abscess, aortic leakage
  • Not useful in differentiating cancer from diverticulitis
Contrast Enema
  • Able to detect abscesses & other colonic diseases eg ischemic colitis, inflammatory bowel disease (IBD) that may present in a similar manner
    • Not an imaging test of choice during an acute episode of abdominal pain
  • May underestimate the severity of the disease because it cannot demonstrate the extramural nature of diverticulitis
  • Cost of the test is low & test is available in most centers
  • Use of water-soluble contrast media is advisable
    • Barium contrast is generally not recommended because of the risk of colonic perforation & subsequent peritonitis
  • Criteria for diagnosis of diverticulitis include the following:
    • Presence of diverticula, intramural mass, mass effect or sinus tract
    • Extravasation of contrast suggests perforation

Transabdominal Ultrasound

  • Safe noninvasive test but is examiner-dependent
  • Criteria for the diagnosis of diverticulitis include wall thickening, abscess & rigid hyperechogenicity of the colon
  • The test is valuable in women of childbearing age who present with left lower abdominal quadrant pain & fever
    • More sensitive than computed tomography (CT) or contrast enema in detecting gynecologic abnormalities eg ectopic pregnancy & pelvic inflammatory disease (PID)

Abdominal X-ray

  • Provides limited information except in cases where perforation or obstruction are suspected
  • Plain & upright films may show ileus, free air (pneumoperitoneum) or obstruction

Evaluation

The management of diverticulitis depends on the clinical presentation, severity of inflammation, location of the lesion & presence of concomitant diseases

Uncomplicated Diverticulitis

  • Refers to diverticulitis without associated abscess, obstruction, fistula, perforation, or peritonitis

Complicated Diverticulitis

  • Refers to diverticulitis with complications including abscess, obstruction, fistula, perforation, stricture, or peritonitis
  • Divided into stages by the Hinchey classification
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