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CDHB

Suspected Diverticulitis

Diverticulitis can be classified as uncomplicated, which usually responds to conservative measures and antibiotics, or complicated, such as perforation, abscess, fistula or obstruction. These usually require intervention in addition to antibiotics.

History, Examination and Investigations

• Left iliac fossa pain, tenderness, fever, past history of diverticular disease.
• CBC + diff, CRP, Na, K, creatinine, amylase, urinalysis.
• Erect CXR ± abdominal X-ray (if bowel obstruction suspected)
• CT abdomen/pelvis if:
  • No previous documented diverticulosis
  • Moderate/severe clinical presentation (severe sepsis, generalized peritonitis)
  • Not responding to IV antibiotics after 48-72 hours

Management

Uncomplicated diverticulitis:

• IV antibiotics: IV amoxicillin 1 g q6h, IV gentamicin (refer to the gentamicin/tobramycin dosing guidelines in the Pink Book), and IV metronidazole 500 mg q8h.
• IV fluids as clinically indicated.
• Clear fluids PO increasing to light diet as tolerated.
• Monitor temp, pulse, BP, creatinine, and urine output.
• Deterioration or no improvement after 72 hours:
  • Reassess and consider CT abdo/pelvis looking for complications.
• Improvement:
  • Change to oral antibiotics when afebrile for 24 hours, normal pulse and falling WBC. Give amoxicillin/ clavulanate 625 mg TDS PO for 7-10 days.
  • GP follow up in 2 weeks.
  • Colonoscopy at 6 weeks unless:
    • CT proven uncomplicated diverticulitis and no other clinical features mandating colonoscopy.
    • Recent complete colonoscopy (<24 months).

Complicated Diverticulitis (discuss with admitting Consultant Surgeon):

• Free perforation - discuss with Surgeon and prepare for theatre.
• Abscess:
  • <5 cm - manage as for uncomplicated diverticulitis
  • >5 cm - radiological guided percutaneous drainage where possible
• Fistula/obstruction - discuss with Surgeon, management usually operative but will require preoperative investigation and management on case by case basis.
• Complicated cases will generally require surgical outpatient follow up at 6 weeks.

Topic Code: 66066