An uncomplicated Synopsis of AFP's "Diagnosis and Management of Acute Diverticulitis"

A brief synopsis of:
Diagnosis and Management of Acute Diverticulitis, THAD WILKINS, MD; KATHERINE EMBRY, MD; and RUTH GEORGE, MD, Georgia Regents University, Augusta, Georgia
http://www.aafp.org/afp/2013/0501/p612.pdf

Am Fam Physician. 2013 May 1;87(9):612-620.

     Diverticulitis is simply inflammation of the colon. If there is an associated abscess, phlegmon, obstruction, bleeding, fistula, or perforation, then it is known as complicated diverticulitis. Asians more commonly have it in the ascending colon, whereas westerners have it in the sigmoid and descending colon. If there is no inflammation and only outpouching (diverticula), it is known as diverticulosis. There is a genetic prevalence in diverticulitis, but lack of dietary fiber, lack of exercise, aspirin use, NSAID use, and obesity are contributing factors. 
    The diverticulitis patient will present with constant, acute LLQ pain. The patient may also have fever, constipation, nausea, diarrhea, dysuria and anorexia.  Symptoms such as rebound tenderness, rigidity, and lack of peristalsis would suggest peritonitis over diverticulitis. Pregnancy should be ruled out, and a CBC can be done to look for an elevated WBC. An FOBT may be conducted to rule out occult GI bleeding. A CRP above 50 mg/L in a patient who isn't vomiting is highly suggestive of acute diverticulitis. A CT may show bowel wall thickening, fat stranding, free air, abscess, or inflammation. 
     If the severity is mild, without peritoneal signs,  and the patient can tolerate PO intake, then the patient can be treated on an outpatient basis. The patient would be given a clear liquid diet with a follow up appointment in 2-3 days. If the symptoms persist, then an antibiotic can be started, such as TMP/SMX, Augmentin, or fluoroquinolones. 
     If the patient is having moderate/ severe symptoms, peritoneal signs, or mild symptoms that are persistent,  suspicion of complicated diverticulitis may be in order. The patient may not tolerate PO intake.  At this point, the patient should be admitted.  IV fluids and antibiotics, such as Zosyn, Timentin, Invanz, Tygacil, or fluoroquinolones can be given. If the diverticulitis appears life threatening, Primaxin, Meropenem or Doripenem can be considered.  In about 2-4 days, the fever should resolve, pain should decrease, and WBC should normalize. Patients should be transitioned from IV to oral antibiotics once a clinical improvement is seen. If the patient is not improving and imaging shows abscess or obstruction, then a surgical consult may be in order  A localized abscess may need CT-guided drainage. Surgical colectomies have been on the decline, with laparoscopic drainage, washout or resection on the rise. A colonoscopy is recommended in complicated diverticulitis, 4-6 weeks after resolution. 
     Prevention includes increasing dietary fiber, more exercise, and weight loss in overweight patients. The theory that eating seeds, nuts, or popcorn increases the likelihood of diverticulitis has been debunked.