What is a normal inpatient workup for acute diverticulitis?

From the Guidelines

A normal inpatient workup for diverticulitis typically includes laboratory tests, imaging studies, and clinical assessment, with antibiotic therapy reserved for patients with complicated disease or those who are immunocompromised, have comorbidities, or present with refractory symptoms or vomiting, as recommended by the AGA clinical practice update on medical management of colonic diverticulitis 1.

Key Components of the Workup

• Blood tests: complete blood count, comprehensive metabolic panel, and C-reactive protein or erythrocyte sedimentation rate to assess for infection and inflammation
• Imaging studies: CT scan of the abdomen and pelvis with IV and oral contrast to confirm diagnosis and assess disease severity
• Clinical assessment: evaluation of patient's symptoms, medical history, and physical examination to determine the need for antibiotic therapy

Antibiotic Therapy

• Reserved for patients with complicated diverticulitis, immunocompromised patients, or those with comorbidities, refractory symptoms, or vomiting 1
• Broad-spectrum coverage for gram-negative rods and anaerobes, such as a combination of ciprofloxacin and metronidazole, or a single agent like piperacillin-tazobactam

Additional Considerations

• Patients should be kept NPO initially, with IV fluid resuscitation using crystalloids like normal saline or lactated Ringer's solution
• Pain management with opioid analgesics may be necessary, avoiding anticholinergics and NSAIDs
• Daily monitoring of vital signs, abdominal examination, and laboratory values helps track clinical improvement

Evidence-Based Recommendations

• The AGA clinical practice update on medical management of colonic diverticulitis recommends selective use of antibiotics in patients with uncomplicated diverticulitis, reserving antibiotic therapy for patients with complicated disease or those who are immunocompromised, have comorbidities, or present with refractory symptoms or vomiting 1
• The WSES guidelines for management of intra-abdominal infections also recommend selective use of antibiotics, reserving antibiotic therapy for patients with complicated intra-abdominal infections or those who are immunocompromised, have comorbidities, or present with refractory symptoms or vomiting 1

From the Research

Normal Diverticulitis Inpatient Workup

• Initial laboratory studies for patients with acute diverticulitis include:
  • Complete blood count
  • Basic metabolic panel
  • Urinalysis
  • Measurement of C-reactive protein 2
• Imaging tests:
  • Computed tomography (CT) is the most commonly performed imaging test to establish the diagnosis and the extent and severity of disease, and to exclude complications in selected patients 2
• Inpatient management:
  • Intravenous fluid resuscitation
  • Intravenous antibiotics 2
  • Patients with a localized abscess may be candidates for CT-guided percutaneous drainage 2
• Surgical intervention:
  • Fifteen to 30 percent of patients admitted with acute diverticulitis require surgical intervention during that admission 2
  • Laparoscopic surgery results in a shorter length of stay, fewer complications, and lower in-hospital mortality compared with open colectomy 2

Diagnosis and Management

• Uncomplicated diverticulitis is localized diverticular inflammation, whereas complicated diverticulitis is diverticular inflammation associated with an abscess, phlegmon, fistula, obstruction, bleeding, or perforation 2
• Complicated diverticulitis usually requires inpatient hospital admission, treatment with antibiotics, and consideration for intervention including operative management 3
• The use of antibiotics in acute uncomplicated diverticulitis could slightly increase complications and result in a minor or no difference in the risk of recurrence and need for urgent surgery 4

Treatment

• Antibiotic therapy aimed at anaerobes and gram-negative rods is first-line treatment for diverticulitis 5
• Whether treatment is administered on an inpatient or outpatient basis is determined by the clinical status of the patient and his or her ability to tolerate oral intake 5
• Surgical consultation is indicated for disease that does not respond to medical management or for repeated attacks that may be less likely to respond to medical therapy and have a higher mortality rate 5