Management of Diverticular Disease

Abstract and Introduction

Introduction

Diverticular disease comprises diverticulosis and diverticulitis. Diverticulosis—the presence of diverticula without inflammation—is very common, affecting approximately 50% of Americans by age 60 years, although most patients remain asymptomatic.^[1–3] Diverticula are pouches or sacs within the colon that occur normally or via herniation of the mucous lining. However, roughly 5% to 20% of patients with diverticulosis will develop inflammation and subsequent sequelae.^[3,4] Once there is inflammation, the condition is called diverticulitis. It is thought that a micro- or macroperforation is the precipitating factor in the development of diverticulitis.^[4] The perforation may be the result of increased intraluminal pressure or thickened fecal matter in the neck of the diverticulum.^[4]

In the Western world, the left colon (descending and sigmoid) is the area most often affected, with approximately 95% of the cases of acquired diverticular disease involving the sigmoid colon (which is closest to the rectum).^[3,5,6] In Asian countries, the right colon (cecum and ascending) is most often affected.^[2] This suggests a genetic, lifestyle, or environmental component for developing right-sided diverticular disease.^[5] With most right-sided diverticula, there is an outpouching of all three layers of the colonic wall (mucosa, submucosa, and muscle layer).^[3] This constitutes a "true" diverticulum.^[3,7] However, most left-sided diverticula involve only the mucosa and the submucosa. When a diverticulum affects only the mucosa and the submucosa, it is called a pseudodiverticulum.^[3,7] Patients with right-sided diverticular disease are often 20% younger than left-sided patients when they first present with the disease. Their pain is in the right lower quadrant, and it is often difficult to distinguish from appendicitis.^[2]

Cite this: Management of Diverticular Disease - Medscape - Dec 01, 2010.

Table 1. Classification of Diverticulitis^a
Grade	Description	Recommendation
I	Symptomatic uncomplicated disease; fever, abdominal pain	Perform colonoscopy or barium enema to rule out neoplasms and colitis
II	Recurrent symptomatic disease	Perform CT scan or barium enema
III	Complicated disease; abscess, hemorrhage, stricture, fistula, phlegmon, purulent and fecal peritonitis, perforation, obstruction	Perform a CT scan

^a According to the European Association of Endoscopic Surgeons.
Source: Reference 3.

Table 2. Outpatient Medication Therapy: Antibiotic Regimens
Augmentin 875 mg bid (amoxicillin and clavulanate potassium 875 mg/125 mg)
OR
Metronidazole 500 mg tid and Cipro (ciprofloxacin) 500 mg bid
OR
Metronidazole 500 mg tid and Bactrim DS (trimethoprim-sulfamethoxazole 160/800 mg) bid orally for 7–10 days, or until the patient is afebrile for 3–5 days

Source: Reference 9.

Table 3. Inpatient Medication Therapy: Antibiotic Regimens
Anaerobic Coverage	Gram-Negative Coverage	Other
Metronidazole	AND aminoglycoside	OR
OR	(gentamicin or tobramycin)	Second-generation
Clindamycin	OR	cephalosporin
	Monobactam (aztreonam)	(cefoxitin or cefotetan)
	OR	OR
	Third-generation cephalosporin (ceftriaxone or ceftazidime or cefotaxime)	Beta-lactamase inhibitor combination (ampicillin-sulbactam or ticarcillin-clavulanate)

Source: References 4, 9.

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Management of Diverticular Disease

Abstract and Introduction

Introduction

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Tables

Tables

References

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