DIVERTICULITIS

History:
     Mild-moderate LLQ pain, Dull, achy or crampy
          With perforation pain may become generalized
     Fever, Malaise, N/V, anorexia
     Change in bowel habits = constipation alternating with diarrhea, Chg in caliber
     Urinary frequency, dysuria

Physical Exam:
     LLQ pain, tenderness and guarding
     Distension
     Palpable tender mass (rectal & pelvic exam)
     BS high pitched or hyperactive if obstruction present
     Guaiac positive stools

Labs:
     WBC = mild - moderate leukocytosis
     Previous BE may show diverticulosis
     CT (water soluble contrast during acute phase); useful for staging

Differential Diagnosis:
     Appendicitis, PID, endometriosis, IBD, perforated colonic Ca, obstruction,
     Ischemic colitis, IBS

Treatment:
     Medical Management
          1. IV hydration, NG suction, NPO
          2. IV Antibiotics for gram negative and anaerobic bacteria
               Gentamicin & Clindamycin
               Metronidazole
               Cefoxitin, Cefotan, Timentin, Zosyn
              ** Give until afebrile, WBC normal, tenderness resolved
          3.  Consider IV Steroids = Solumedrol
          4. Oral Antibiotics = for mild attacks or after improvement on IV antibiotics
               ** Give for 1-2 weeks
          5. Clear Liquid Diet then Low residue diet 2 - 4 weeks, then High Fiber Diet

     Surgical Treatment:
          Indications for surgery
               1. Elective resection for repeated attacks
               2. Failure of medical management
               3. Obstruction, fistula, inability to exclude Ca
               4. Acute attack I patient < 50, or immunocompromised
          Procedures:
               1. Single Stage:
                    Resect diseased colon and anastamosis performed
                         **Bowel must be prepped
                    Can drain pericolic abcess then perform single stage Resection
               2. Two Stage Procedure
                    Primary Resection with colostomy or Hartman's Pouch
                    Reanastamosis 2 - 6 months later
                    Used for emergent surgery on unprepped bowel