gastrointestinal disorders
Colonic Diverticulitis
Treatment of Colonic Diverticulitis
Varies with severity Sometimes antibiotics CT-guided percutaneous drainage of abscess Sometimes surgery A patient who is not very ill is treated at home with rest. Symptoms usually subside rapidly. An unrestricted diet, if tolerated, is preferable for patients with acute uncomplicated diverticulitis. No data support dietary restrictions. Patients with more severe symptoms (eg, moderate to severe pain, fever, marked leukocytosis) should be hospitalized, as should patients takingprednisone(who are at higher risk of perforation and general peritonitis). Treatment is bed rest, nothing by mouth (for patients with acute complicated diverticulitis), and IV fluids. Antibiotics were traditionally recommended for all cases of acute diverticulitis whether or not they were complicated. However, data suggest that antibiotics may not improve outcome in uncomplicated diverticulitis, therefore, patients who are otherwise healthy and have uncomplicated sigmoid diverticulitis can be safely managed without antibiotics. (See also the American Gastroenterological Association's2015 guidelines on management of acute diverticulitis.) Antibiotic therapy should be reserved for patients with acute complicated diverticulitis, immunosuppression, sepsis, or significant comorbidities. If antibiotics are used, they should cover gram-negative rods and anaerobic bacteria. Oral antibiotic regimens that can be given to outpatients for whom treatment is elected include 7 to 10 days of Metronidazole(500 mg every 8 hours) plus a fluoroquinolone (eg,ciprofloxacin500 mg every 12 hours) Metronidazole(500 mg every 8 hours) pluscephalexin(500 mg every 6 or 8 or 12 hours) Metronidazole(500 mg every 8 hours) plustrimethoprim/sulfamethoxazole (800/160 mg every 12 hours) Amoxicillin(875 mg every 12 hours) plus clavulanate (125 mg every 12 hours) Moxifloxacin(400 mg once/day for patients unable to take penicillins ormetronidazole) IV antibiotic regimens for hospitalized patients are selected based on many factors, including the severity of illness, risk of adverse outcome (eg, due to other illnesses, older age, immunosuppression), and likelihood of resistant organisms. Many regimens exist. There are no well-defined standards relating abscess size to the need for surgery or interventional (ultrasound- or CT-guided) drainage. However, small pericolic abscesses (less than 2 to 3 cm in diameter) often resolve with broad-spectrum antibiotics and bowel rest alone. If response is satisfactory, the patient remains hospitalized until symptoms are relieved; a soft diet is resumed as tolerated. After the episode resolves, patients should consume a high-fiber diet and avoid routine analgesic use of nonsteroidal anti-inflammatory drugs (NSAIDs) oraspirinto prevent recurrence. CT-guided percutaneous or endoscopic ultrasound-guided drainage is becoming the standard of care for larger abscesses (over 3 cm in diameter), for abscesses that do not resolve with antibiotics, and/or for clinical deterioration. However, abscesses that are multiloculated, inaccessible, or not improving with drainage require surgical intervention. Surgery is required immediately for patients with free perforation or when feculent peritonitis is suspected based on clinical examination or imaging. Other indications for surgery include severe symptoms that do not respond to nonsurgical treatment within 3 to 5 days and increasing pain, tenderness, and fever. About 15 to 20% of people admitted with acute diverticulitis require surgery during that admission ( Treatment references ). surgical resection was previously recommended based on the number of recurrences. Currently, the American Society of Colon and Rectal Surgeons (ASCRS) and other practice guidelines recommend a case-by-case evaluation rather than mandatory elective segmental colectomy after a second episode ( Treatment references – surgical recommendations vary. An elective segmental colectomy is not routinely recommended for patients after a conservatively managed episode of acute complicated diverticulitis ( Treatment references ). Surgery is recommended for patients with chronic complicated diverticulitis where fistulas and persisting abscesses are present. The involved section of the colon is resected. The ends can be reanastomosed immediately in healthy patients without perforation, abscess, or significant inflammation. Other patients have a temporary colostomy with anastomosis carried out in a subsequent operation after inflammation resolves and their general condition improves. 