Most patients who present with acute diverticulitis complain of acute onset left lower quadrant abdominal pain. Fever is often present as well and the patient may report bowel changes such as diarrhea or constipation. Bleeding is not generally associated with acute infection, and although patients may report association with a particular type of food, diet is generally not a contributing factor. Diagnostic studies should be aimed at both demonstrating the presence of inflammation as well as ruling out complications such as abscess, fistula, or free perforation. Computed tomography (CT) scan is probably the single best test in the setting of presumed acute inflammation because it reliably detects the location of inflammation and also detects any associated abscess that may be present. Fistulas may also be demonstrated if air is seen in adjacent structures such as the urinary bladder. Colonoscopy and contrast enema studies are less desirable in the acute setting as they carry the risk of extravasation of contrast or air via the involved diverticulum
The presence of diverticulitis alone implies perforation of a diverticulum at some level. Most cases are mild and associated with microperforation of a diverticulum that allows intralumenal bacteria to escape and incite a peri-colonic inflammatory process. In general, the treatment of acute diverticulitis not associated with abscess, stricture, fistula, or free perforation is broad spectrum antibiotic coverage with or without diet alterations. Seventy percent or more of patients who have recovered from an uncomplicated episode of diverticulitis will have no further problems in their lifetime. However, after a second uncomplicated attack, the odds of further episodes are > 50%. Recurrent episodes of radiographically documented diverticulitis, especially in young patients, are an indication for elective surgical resection of the involved segment.
Diverticulitis is considered complicated when the disease process is associated with abscess, fistula to and adjacent an organ, stricture, or free perforation into the peritoneal cavity. As with uncomplicated disease, the best initial diagnostic test is a CT scan in any patient suspected of having complicated disease. Depending on the type of complication present, patients may present with symptoms similar to uncomplicated disease, or they may present in distress with signs of an acute abdomen. Patients with stricture formation may have few acute symptoms as the complication generally develops slowly over time. They will however likely describe a history of multiple episodes of acute diverticulitis. If stricture is suspected and the patient lacks acute symptoms, colonoscopy or a contrast study is indicated to further evaluate the diseased segment as well as the more proximal colon. Similarly, patients with fistulas to pelvic organs may have few acute symptoms but are likely to report problems such as recurrent urinary tract infection, vaginal discharge, or pneu-maturia. Colonoscopy is not likely to be helpful, and contrast studies may or may not demonstrate the fistula tract (Figure 103-1). If a fistula to the bladder is suspected but cannot be definitely demonstrated on contrast study, oral administration of 30 cc of activated charcoal can be helpful. Urinalysis performed daily should yield charcoal crystals on examination if a fistula is present. In the absence of acute symptoms, patients with stricture or fistula can often be treated electively and do not need urgent hospital admission.
In contrast, patients who present with abscess formation or free intraperitoneal perforation are often acutely ill and require hospitalization and, occasionally, urgent operative intervention. In the past most patients who presented with abscess or perforation were treated with urgent resection of the diseased segment and diversion via either a colostomy or ileostomy. Recent advances in interventional radiology and the aggressive use of total parenteral nutrition (TPN) and intravenous (IV) antibiotics have changed the approach to many of these patients, allowing for an elective resection with avoidance of a diverting ostomy.
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