What are the typical presentations and management strategies for diverticulosis?

Presentation and Management of Diverticulosis

Diverticulosis is commonly asymptomatic, but when symptomatic, it typically presents with left lower quadrant abdominal pain, fever, change in bowel habits, nausea, and elevated inflammatory markers, requiring CT imaging for definitive diagnosis and classification into uncomplicated or complicated disease. 1, 2

Clinical Presentation

Asymptomatic Diverticulosis

• Most patients with diverticulosis (presence of diverticula) remain asymptomatic
• Only 1-4% of patients with diverticulosis develop acute diverticulitis in their lifetime 3

Symptomatic Presentation

• Common symptoms:

  • Abdominal pain (typically left lower quadrant)
  • Fever
  • Change in bowel habits
  • Nausea without vomiting
  • Elevated white blood cell count and/or C-reactive protein (CRP) 1

• Important note: Clinical suspicion alone is correct in only 40-65% of patients, necessitating imaging confirmation 1

Diagnostic Approach

Imaging

• CT scan with oral and IV contrast: Gold standard with 95-99% sensitivity/specificity 1, 3
• Ultrasonography: Alternative that avoids radiation but is operator-dependent
• MRI: Very sensitive but less specific than CT; not typically used in acute settings
• Plain radiographs: Cannot confirm diagnosis but useful for assessing complications like perforation or obstruction 1

Laboratory Tests

• Complete blood count (look for leukocytosis)
• C-reactive protein (elevated in inflammatory conditions)
• Procalcitonin (can help differentiate severity) 2

Classification

Uncomplicated Diverticulitis (85% of cases)

• Thickening of colon wall
• Peri-colonic inflammatory changes
• No abscess, perforation, fistula, or obstruction 1, 3

Complicated Diverticulitis (12-15% of cases)

• Presence of:
  • Abscess (most common complication)
  • Peritonitis
  • Obstruction
  • Stricture
  • Fistula formation 1

Management Strategies

Uncomplicated Diverticulitis

1. Conservative management:

   • Observation with pain control (typically acetaminophen)
   • Clear liquid diet initially, advancing as tolerated 2, 3

2. Selective antibiotic use (not routine) for patients with:

   • Systemic symptoms (persistent fever, chills)
   • Increasing leukocytosis
   • Age >80 years
   • Pregnancy
   • Immunocompromised status
   • Significant comorbidities (cirrhosis, CKD, heart failure, poorly controlled diabetes) 2, 3

3. First-line antibiotics when indicated:

   • Oral: amoxicillin-clavulanate or cefalexin with metronidazole
   • IV (if unable to tolerate oral): ceftriaxone plus metronidazole or ampicillin/sulbactam 2, 3

Complicated Diverticulitis

1. Intravenous antibiotics:

   • Ceftriaxone plus metronidazole
   • Piperacillin-tazobactam
   • Ampicillin/sulbactam 2, 3

2. Abscess management:

   • Small abscesses (<4-5 cm): Antibiotics alone
   • Large abscesses (≥4-5 cm): Percutaneous drainage plus antibiotics 2

3. Surgical intervention:

   • Immediate surgical intervention for peritonitis
   • Fluid resuscitation and prompt antibiotic administration
   • Damage control surgery for hemodynamically unstable patients 2

Follow-up and Prevention

Colonoscopy

• Recommended 6-8 weeks after resolution of acute symptoms
• Essential after complicated diverticulitis
• May be deferred if high-quality colonoscopy was performed within the past year 1

Prevention Strategies

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of NSAIDs, opiates, and corticosteroids
• Weight management (aim for normal BMI) 1, 2

Special Considerations

Smoldering Diverticulitis

• Approximately 5% of patients experience persistent abdominal pain with continued evidence of inflammation on CT scan 1

Elderly Patients

• Often present atypically (only 50% with typical lower quadrant pain)
• Only 17% present with fever
• 43% do not have leukocytosis
• Lower threshold for CT imaging and antibiotic therapy recommended 2

Recurrent Diverticulitis

• Elective segmental resection should not be based solely on number of episodes
• Decision should be personalized based on:
  • Severity of disease
  • Patient preferences and values
  • Risks and benefits of surgery 1

Pitfalls to Avoid

• Relying solely on clinical diagnosis without imaging confirmation
• Routine use of antibiotics for all cases of uncomplicated diverticulitis
• Delaying surgical consultation in cases of peritonitis or hemodynamic instability
• Failing to rule out malignancy, especially after complicated diverticulitis
• Overlooking atypical presentations in elderly patients 1, 2, 3