Diverticulitis

Once you have determined that the patient has acute cholecystitis, admit the patient with IV fluids and analgesic therapy. Do not allow oral intake and use NG suction if there is vomiting or an ileus. The antibiotic choices used most often empirically are ceftriaxone plus metronidazole or piperacillin/tazobactam. Surgery is curative and should be done early if there is a low surgical risk, a high risk of complications, or evidence of perforation, gangrene, empyema, or acalculous cholecystitis.

DIVERTICULITIS

Diverticulitis involves infection or inflammation of a diverticulum in the colon. Because these often obstruct the lumen of the diverticulum, these can lead to a bowel wall phlegmon, perforation, abscess, fistula formation, or peritonitis. Most people have multiple diverticula but rarely have true diverticulitis of more than one of these at a time. Figure 3 shows what diverticulitis looks like:

Figure 3.

The majority of elderly people have diverticulosis, which is largely asymptomatic. Only about 4 percent of patients with diverticulosis develop diverticulitis. Diverticulitis can be acute or chronic with frequent recurrences. The process can be inflammatory or infectious and may be viral or bacterial. There is no relationship between eating seeds, corn, popcorn, or nuts and developing diverticulosis.

Diverticulitis can be uncomplicated or complicated, with the majority being uncomplicated. Complicated disease involves obstruction, perforation, abscess formation, and fistulae. Abscess formation is seen in 15 percent of complicated cases.

Common signs and symptoms include left lower quadrant abdominal pain, the finding of a palpable sigmoid colon, nausea, vomiting, and fever. Bladder irritation can lead to UTI symptoms. Those with abscesses or perforation have a high incidence of classic peritoneal signs. Fistula can present with air or feces in the urine or feces in the vaginal discharge. Abscesses can open out into the skin itself. Bowel obstruction is possible but GI bleeding would be rare.

The diagnosis of acute diverticulitis is best made with an abdominal and pelvic CT scan. After resolution of symptoms, a colonoscopy can be diagnostic. Because other GI or gynecological conditions can mimic diverticulitis, diagnostic testing should be done. An MRI can be done if there are issues about radiation, such as would be seen in pregnant patients.

The treatment largely depends on the severity of the disease process. Some can be managed with a liquid diet at home. Nothing by mouth is recommended for patients with more severe disease. Antibiotics, percutaneous drainage under CT guidance, or surgery may also be indicated. Antibiotics are no longer recommended in all cases, particularly if they are uncomplicated.

If antibiotics are indicated, coverage should be for gram-negative bacteria and anaerobes. Choices include ciprofloxacin plus metronidazole, Bactrim plus metronidazole, amoxicillin plus clavulanate, or moxifloxacin plus metronidazole.

The standard of care for abscesses is percutaneous drainage with ultrasound guidance. Surgery is reserved for those with peritonitis and free perforation or for people that are not responding to conservative treatment. An elective segmental colectomy is