Diverticulitis MDM

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MDM Templates

Uncomplicated Diverticulitis

Patient presents with left lower quadrant abdominal pain. Imaging confirms acute uncomplicated diverticulitis without evidence of abscess, perforation, or obstruction. Well appearing without peritoneal signs. Tolerating PO.

History, exam, and imaging not consistent with other dangerous causes of LLQ pain including colon cancer, ischemic colitis, ovarian torsion, or abdominal aortic aneurysm.

Plan: Oral antibiotics — ciprofloxacin 500 mg BID + metronidazole 500 mg TID for 7–10 days (or amoxicillin-clavulanate 875 mg BID). Clear liquid diet advancing as tolerated.
Disposition: Discharge with strict return precautions for worsening pain, fever, inability to tolerate PO, or bloody stool. Follow up with PCP within 24–48 hours. Patient understands that if symptoms do not improve within 48–72 hours, they may require admission and IV antibiotics.

Complicated Diverticulitis

Patient presents with abdominal pain and imaging demonstrates complicated diverticulitis with evidence of ***. Peritoneal signs present / patient is febrile and ill-appearing.

If abscess amenable to percutaneous drainage:

CT demonstrates a diverticular abscess > 3 cm. IV antibiotics initiated — piperacillin-tazobactam 3.375 g IV. Interventional radiology and surgery consulted regarding percutaneous drainage versus operative management.
Disposition: Admit.

If free perforation or peritonitis:

Imaging demonstrates free air / diffuse peritonitis on exam. Broad-spectrum antibiotics initiated. Surgery consulted emergently for operative management. IV fluid resuscitation.
Disposition: Admit to surgery.

Clinical Education

The Antibiotics Debate

Multiple RCTs now show that uncomplicated diverticulitis resolves without antibiotics. The DIABOLO trial (2017) and AVOD trial (2012) demonstrated no difference in recovery time, complication rates, or recurrence between antibiotics and observation alone in CT-confirmed uncomplicated diverticulitis. The AGA now suggests that antibiotics can be selectively, rather than routinely, used in uncomplicated diverticulitis.[1][2]

In practice, most ED physicians still prescribe antibiotics. This is reasonable — the studies enrolled carefully selected patients with CT confirmation, and the ED is not the ideal setting to make a “no antibiotic” call when follow-up is uncertain. But for a reliable patient with CT-confirmed uncomplicated disease, mild symptoms, and good follow-up, observation alone is supported by evidence.

When antibiotics are used, standard regimens include: ciprofloxacin 500 mg BID + metronidazole 500 mg TID, or amoxicillin-clavulanate 875 mg BID, for 7–10 days. For IV: piperacillin-tazobactam or ceftriaxone + metronidazole.[3]

Imaging Approach

CT abdomen/pelvis with IV contrast is the gold standard. Sensitivity >94%. Findings: pericolonic fat stranding, colonic wall thickening, inflamed diverticula. CT also identifies complications — abscess, perforation, fistula, obstruction — which determine management.[4]

Do you need a CT for every case? For a classic presentation (prior episodes, typical LLQ pain, low-grade fever, no peritoneal signs) in a reliable patient, some guidelines suggest clinical diagnosis alone is acceptable. However, in the ED, CT is valuable because it confirms the diagnosis, rules out complications, and excludes mimics (colon cancer in particular).

Oral contrast is not necessary for diverticulitis diagnosis. IV contrast alone is sufficient and avoids the delay and patient discomfort of oral prep.

Hinchey Classification

Stage Description Management
I Pericolic abscess (confined) IV antibiotics ± percutaneous drainage if > 3 cm
II Pelvic or distant abscess Percutaneous drainage + IV antibiotics
III Purulent peritonitis (ruptured abscess) Emergent surgery
IV Fecal peritonitis (free perforation) Emergent surgery (highest mortality)

Hinchey I and II are typically managed non-operatively with antibiotics and drainage. Hinchey III and IV require emergent operative intervention — usually Hartmann procedure (resection with end colostomy).[5]

Right-Sided Diverticulitis

Right-sided diverticulitis mimics appendicitis. More common in Asian populations and younger patients. CT is essential to distinguish the two — pericolonic inflammation centered on the cecum/ascending colon with adjacent diverticulum, rather than an inflamed appendix. Management is the same as left-sided uncomplicated diverticulitis. Surgery is rarely needed.[6]

Special Populations

Immunocompromised patients (steroids, transplant, chemotherapy) have blunted inflammatory responses — may not have fever, leukocytosis, or significant tenderness despite complicated disease. They also have higher perforation rates. Maintain a low threshold for CT and a low threshold for admission and IV antibiotics.[3]

Young patients (<50): Diverticulitis is increasingly diagnosed in younger patients. Previous dogma that “young patients have more aggressive disease” has been challenged — recent data suggest outcomes are similar to older patients. Still, first-episode diverticulitis in a young patient warrants outpatient colonoscopy follow-up to exclude underlying pathology.[7]

The “seeds and nuts” myth is dead. There is no evidence that seeds, nuts, or popcorn cause or worsen diverticulitis. The Nurses’ Health Study actually showed an inverse association. Do not advise dietary restriction of these foods.[8]

Disposition

Discharge if: Uncomplicated on CT, tolerating PO, pain controlled, reliable follow-up within 24–48 hours, immunocompetent, no significant comorbidities.

Admit if: Complicated disease (abscess, perforation, obstruction, fistula), inability to tolerate PO, failed outpatient therapy, immunocompromised, significant comorbidities, unreliable follow-up, or hemodynamic instability.

Outpatient colonoscopy should be recommended 6–8 weeks after resolution of a first episode, particularly in patients over 40 or those with risk factors for colorectal cancer, to exclude an underlying malignancy that can mimic or coexist with diverticulitis.[3]

References

  1. Chabok A et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis (AVOD). Br J Surg. 2012;99(4):532-539. PubMed
  2. Daniels L et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis (DIABOLO). Br J Surg. 2017;104(1):52-61. PubMed
  3. Hall J et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728-747. PubMed
  4. Defined LJ et al. Accuracy of CT diagnosis of diverticulitis. Radiology. 2000;218(1):68-74.
  5. Sartelli M et al. WSES guidelines for the management of acute left-sided colonic diverticulitis in the emergency setting. World J Emerg Surg. 2016;11:37. PubMed
  6. Strate LL et al. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol. 2012;107(10):1486-1493. PubMed
  7. Bharucha AE et al. Temporal trends in the incidence and natural history of diverticulitis. Am J Gastroenterol. 2015;110(11):1589-1596. PubMed
  8. Strate LL et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907-914. PubMed

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