This document defines and discusses diverticulosis, diverticulitis, segmental colitis associated with diverticula (SCAD), and symptomatic uncomplicated diverticular disease (SUDD). It covers the background, definitions, presentations, diagnoses, differential diagnoses, and treatments of these conditions. Diverticulosis is the presence of diverticula (sac-like protrusions of the colonic wall), while diverticulitis is inflammation of the diverticula that can be acute or chronic. SCAD involves chronic inflammation between diverticula, and SUDD includes abdominal pain associated with diverticulosis.

1. Kimberly M.
Treier
PharmD
Candidate 2016
DIVERTICULOSIS AND
DIVERTICULITIS

2.  Diverticulum – sac-like protrusion of colonic wall
 Diverticulosis – presence of diverticulum
 Symptomatic or asymptomatic
 Diverticular disease – symptomatic diverticulosis due to
diverticular bleeding, diverticulitis, segmental colitis
associated with diverticula (SCAD) or symptomatic
uncomplicated diverticular disease (SUDD)
 Diverticulitis – inflammation of diverticulum
 Acute or chronic
 Complicated diverticulitis – diverticulitis with one of the following:
bowel obstruction, abscess, fistula or perforation
 Uncomplicated diverticulitis – diverticulitis without associated
complication
DEFINITIONS

3. BACKGROUND

4. BACKGROUND

5. Diverticulosis Diverticulitis
SUDD
Abdominal pain
- Nonspecific
- Constant or relieved by flatulation/defecation
Bloating and change in bowel habits
Diverticular bleed
Painless hematochezia
- Typical presentation
- Usually self-limiting
Abdominal symptoms
- Usually few due to non-inflammatory process
- Bloating, cramping, urge to defecate
Syncope, lightheadedness, postural dizziness
- With severe bleed
SCAD
Chronic diarrhea
Cramping abdominal pain
- Primarily left lower quadrant
- Intermittent hematochezia
Abdominal pain
- Usually left lower quadrant (sigmoid colon)
- Constant
- Present for several days
Nausea and vomiting
- Bowel obstruction
- Peritoneal irritation
Low-grade fever
Hemodynamic instability/shock
- Perforation
- Peritonitis
Tender mass
- Inflammation or peridiverticular abscess
Abdominal guarding, rigidity, rebound tenderness
Stool positive for occult blood
Change in bowel habits
- Constipation (~50%)
- Diarrhea (~25-30%)
Urinary urgency, frequency, dysuria, fecaluria
- Bladder irritation
- Fistula
PRESENTATION

6. Diverticulosis Diverticulitis
SUDD
History
Physical exam
- Fullness/tenderness in left lower quadrant
- Tender palpable loop of sigmoid colon
Colonoscopy
Diverticular bleed
Physical exam
- Normotensive (usually)
- Normal abdominal exam, may have some
tenderness to palpation
- Blood per rectal exam
Labs
- Hgb: normal (<24h) or low (>24h)
- RBCs: normocytic (acute bleed) or microcytic
(chronic bleed)
- BUN:SCr or urea:SCr: normal (vs. upper GI
bleed)
Colonoscopy
Radiographology
History
Physical exam
- Lower abdominal pain and tenderness
- Pelvic exam (women) to r/o other causes
Labs
- CBC (often see leukocytosis)
- Electrolytes
- R/o UA
- R/o pregnancy test (women)
Labs – suspected perforation and diffuse peritonitis
- Serum aminotransferases
- Alkaline phosphatase
- Bilirubin
- Amylase
- Lipase
Cultures – only patients with diarrhea
- R/o infectious process
Imaging
- CT scan
- Ultrasound
DIAGNOSIS

7. Diverticulosis Diverticulitis
SCAD
Endoscopy
- Inflammation of interdiverticular mucosa
- Reddish lesions, ulcers, edema, diffuse
erosions
Histology
- Chronic inflammatory changes (inflammatory
infiltration, glandular architecture changes,
crypt abscess, crypt hemorrhage)
History
Physical exam
- Lower abdominal pain and tenderness
- Pelvic exam (women) to r/o other causes
Labs
- CBC (often see leukocytosis)
- Electrolytes
- R/o UA
- R/o pregnancy test (women)
Labs – suspected perforation and diffuse peritonitis
- Serum aminotransferases
- Alkaline phosphatase
- Bilirubin
- Amylase
- Lipase
Cultures – only patients with diarrhea
- R/o infectious process
Imaging
- CT scan
- Ultrasound
DIAGNOSIS

8. Diverticulosis Diverticulitis
Diverticular bleed
Massive upper GI bleed
Colon cancer
IBD
Ulcers
Angiodysplasia
Severe hemorrhoidal bleeding
SCAD
Acute uncomplicated diverticulitis
IBD
Medication-associated colitis
Infectious colitis
Solitary rectal ulcer syndrome
Radiation colitis
Colorectal cancer
Acute appendicitis
IBD
Infectious colitis
Ischemic colitis
Other
- Tubo-ovarian abscess
- Ovarian cyst
- Ovarian torsion
- Ectopic pregnancy
- Cystitis
- nephrolithiasis
DIFFERENTIAL DIAGNOSIS

9. Diverticulosis Diverticulitis
SUDD
Dietary modifications
- Clear liquids
- High fiber
Antibiotic
- Broad-spectrum (gram(-) and anaerobes)
Spasmolytics
Anticholinergics
Diverticular bleed
Resuscitation
- Fluids
- Blood products
Endoscopic therapy
- Epinephrine injection
- Endoscopic tamponade
- Banding
Angiographic therapy
- Pharmacologic occlusion
- Mechanical occlusion
Surgery
Dietary modifications
- Clear liquids
- High fiber
- Bowel rest (inpatient, severe cases)
Antibiotic therapy
- May not be necessary
- Target gram (-) rods and anaerobes
- 7-14 days based on symptoms
- Outpatient:
ciprofloxacin 500 mg PO BID +
metronidazole 500 mg PO TID
OR
amox-clav 875/125 mg BID
- Inpatient:
ceftolazone 1 g + tazobactam 0.5 g +
metronidazole 500 mg IV every 8 hours
Anti-inflammatory agents
- Mesalamine
Drainage
- Abscess
Surgery
TREATMENT

10. Diverticulosis Diverticulitis
SCAD
Dietary modifications
- Clear liquids
- High fiber
Antibiotic therapy
1. Ciprofloxacin 500 mg BID + metronidazole 10
mg/kg daily x 10-14 days
2. Mesalamine 800 mg TID x 7-10 days
3. Mesalamine 1600 mg TID
4. Prednisone 40 mg daily x 7 days, then taper
over 6 weeks
5. Recurrent symptoms: long-term ciprofloxacin
6. Steroid-refractory/dependent: segmental
resection
Asymptomatic
High fiber
Low-fat
Physical activity
Dietary modifications
- Clear liquids
- High fiber
- Bowel rest (inpatient, severe cases)
Antibiotic therapy
- May not be necessary
- Target gram (-) rods and anaerobes
- 7-14 days based on symptoms
- Outpatient:
ciprofloxacin 500 mg PO BID +
metronidazole 500 mg PO TID
OR
amox-clav 875/125 mg BID
- Inpatient:
ceftolazone 1 g + tazobactam 0.5 g +
metronidazole 500 mg IV every 8 hours
Anti-inflammatory agents
- Mesalamine
Drainage
- Abscess
Surgery
TREATMENT

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 Salzman, H, Lillie D. Diverticular Disease: Diagnosis and Treatment. Am
Fam Physician. 2005 Oct 1;72(7):1229-1234
 Young-Fadok T, Pemberton JH. Colonic diverticular bleeding. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA. (Accessed on 19 April 2016.)
 Young-Fadok T, Pemberton JH. Segmental colitis associated with
diverticulosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accessed on 19 April 2016.)
 Pemberton JH, Young-Fadok T. Clinical manifestations and diagnosis of
acute diverticulitis in adults. In: UpToDate, Post TW (Ed),
UpToDate, Waltham, MA. (Accessed on 19 April 2016.)
 Pemberton JH, Young-Fadok T. Nonoperative management of acute
uncomplicated diverticulitis. In: UpToDate, Post TW (Ed),
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REFERENCES