Surgical Emergencies
Question 150 of 180
A 71 year old woman, with known diverticular disease, presents to the Emergency Department with a persistent left lower quadrant abdominal pain and a fever. You diagnose acute diverticulitis and decide she requires oral antibiotics. Which antibiotic is the most appropriate first line choice for this patient?
Answer:
- For people with uncomplicated acute diverticulitis who are systemically unwell, immunosuppressed or with significant comorbidity:
- Offer oral antibiotics if the person with acute diverticulitis is systemically unwell but does not meet the criteria for referral for suspected complicated acute diverticulitis.
- First choice antibiotic: co-amoxiclav 500/125 mg three times daily for 5 days.
Diverticular Disease
Surgical Emergencies
Last Updated: 5th September 2022
Pathophysiology
Diverticula are sac-like protrusions of mucosa through the muscular wall of the colon. They are usually multiple, 5–10 mm in diameter, and occur in the sigmoid and descending colons in about 85% of people.
The exact cause of diverticulosis and diverticulitis is not known, but diverticulum formation may be associated with a low-fibre diet. This lowers stool bulk, slows transit times, and increases intraluminal pressure. This is theorised to promote herniation of the mucosa through relatively weak areas adjacent to the vasa recta (where blood vessels penetrate the wall).
- Diverticulosis is a condition where diverticula are present without symptoms.
- Diverticular disease is a condition where diverticula cause symptoms, such as intermittent lower abdominal pain, without inflammation and infection.
- Diverticulitis is a condition where diverticula become inflamed and may be caused by infection, typically causing severe lower abdominal pain, fever, general malaise, and occasionally rectal bleeding.
- 'Uncomplicated' diverticulitis refers to diverticular inflammation without symptoms of acute abdomen, or signs of perforation or abscess formation.
- 'Complicated' diverticulitis refers to diverticulitis associated with complications, such as abscess, peritonitis, fistula, obstruction, or perforation.
Risk factors
The exact cause for the development of diverticular disease and diverticulitis is not known, but the following risk factors may be involved:
- Older age
- Genetic
- Low-fibre diet
- Diet rich in red meat
- Smoking
- Obesity
- Drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
- Immunosuppression
Complications
Complications of diverticular disease include:
- Diverticular haemorrhage
- Occurs in about 15% of people with diverticulosis, diverticular disease, or diverticulitis
- Bleeding occurs where the penetrating blood vessels responsible for the bowel wall weakness run over the diverticulum, making them vulnerable to injury
- Bleeding is usually abrupt and painless
- One-third of bleeds are massive, requiring emergency transfusion
- Bleeding stops spontaneously in 70–80% of cases
- Intra-abdominal abscess formation e.g. pericolic or pelvic abscess
- Perforation and peritonitis
- Stricture and fistula formation
- Intestinal obstruction
- Sepsis
Clinical features
- Diverticulosis
- Asymptomatic and in most people remains undiagnosed.
- It may present with a large, painless rectal bleed, or be found incidentally during investigation for other symptoms.
- Diverticular disease
- Intermittent abdominal pain in the left lower quadrant.
- Pain may be triggered by eating and may be relieved by the passage of stool or flatus.
- Tenderness in the left lower quadrant on abdominal examination.
- Other signs and symptoms include bloating, constipation, diarrhoea, nausea, rectal bleeding.
- Diverticulitis
- Constant abdominal pain, usually severe and starting in the hypogastrium before localising in the left lower quadrant, with any of the following:
- Fever.
- Sudden change in bowel habit and rectal bleeding or passage of mucus from rectum.
- Tenderness in the left lower quadrant, a palpable abdominal mass or distention on abdominal examination, with a previous history of diverticulosis or diverticulitis.
- Constant abdominal pain, usually severe and starting in the hypogastrium before localising in the left lower quadrant, with any of the following:
- Complications of diverticulitis
- Intra-abdominal abscess formation — suggested by an abdominal mass on examination or peri-rectal fullness on internal rectal examination (for example due to a low-lying pelvic abscess).
- Perforation and peritonitis — suggested by abdominal rigidity, guarding, and rebound tenderness on examination.
- Sepsis — suggested by altered mental state, raised respiratory rate, low systolic blood pressure, raised heart rate, low tympanic temperature, no urine output or skin discolouration.
- Stricture and fistula formation — the presence of faecaluria, pneumaturia, pyuria or passage of faeces through the vagina suggests colovesical fistula.
- Intestinal obstruction — suggested by colicky abdominal pain, absolute constipation, vomiting, inability to pass flatus, and abdominal distention.
Management
- Diverticulosis
- If asymptomatic diverticulosis has been found incidentally while investigating other symptoms, no further investigations are needed.
- Provide advice on diet and lifestyle, fluid intake, stopping smoking, weight loss and exercise.
- Diverticular disease
- Arrange urgent admission if a person with diverticular disease has significant rectal bleeding (for example, if the person is haemodynamically unstable), as urgent blood transfusion may be required.
- If a person is symptomatic but does not need admission:
- Advise the person to avoid nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesia (such as codeine) if possible, due to the potential increased risk of diverticular perforation.
- Provide advice on diet and lifestyle, fluid intake, stopping smoking, weight loss and exercise as for people with diverticulosis.
- Consider offering:
- Bulk-forming laxatives if a high-fibre diet is unacceptable to the person or it is not tolerated, or if symptoms of constipation or diarrhoea persist.
- Simple analgesia (for example paracetamol), as needed if the person has ongoing abdominal pain.
- An antispasmodic (for example, mebeverine) if the person has abdominal cramping.
- Acute diverticulitis
- For people with uncomplicated acute diverticulitis who are systemically well:
- Consider a no antibiotic prescribing strategy
- Offer simple analgesia, for example paracetamol
- Advise the person to re‑present if symptoms persist or worsen.
- For people with uncomplicated acute diverticulitis who are systemically unwell, immunosuppressed or with significant comorbidity:
- Offer oral antibiotics if the person with acute diverticulitis is systemically unwell but does not meet the criteria for referral for suspected complicated acute diverticulitis.
- First choice antibiotic: co-amoxiclav 500/125 mg three times daily for 5 days
- For people with suspected complicated acute diverticulitis:
- Offer FBC, U&Es and CRP; if inflammatory markers are raised, offer a contrast CT scan within 24 hours of hospital admission to confirm diagnosis and help plan management (if inflammatory markers are not raised, think about the possibility of alternative diagnoses).
- Offer intravenous antibiotics to people with suspected complicated acute diverticulitis; review intravenous antibiotics within 48 hours or after scanning if sooner and consider stepping down to oral antibiotics where possible (if the person has CT-confirmed uncomplicated acute diverticulitis, review the need for antibiotics and discharge them depending on any co-existing medical conditions).
- First choice antibiotics:
- Co-amoxiclav
- Cefuroxime with metronidazole
- Amoxicillin with gentamicin and metronidazole
- Ciprofloxacin with metronidazole
- Refer to surgery for consideration of surgical options which may include:
- Percutaneous drainage of large abscesses.
- Laparoscopic lavage.
- Simple colostomy formation.
- Sigmoid resection with colostomy (Hartmann's procedure).
- Sigmoid resection with primary anastomosis with or without a diverting stoma.
- For people with uncomplicated acute diverticulitis who are systemically well:
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
