Diverticulitis: A Primer for Primary Care Providers
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Expires July 31, 2019
Treatment of this common complication of diverticular disease is predicated on whether the presentation signals uncomplicated or complicated disease. While some uncomplicated cases require hospitalization, many are amenable to primary care outpatient, and often conservative, management. The longstanding practice of antibiotic treatment of uncomplicated cases is now considered a selective, rather than a routine, option.
CLINICAL PRESENTATION
The clinical presentation of diverticulitis typically depends on the severity of inflammation and the presence (or absence) of complications. The most common presenting symptom is left lower-quadrant abdominal pain, which occurs in approximately 70% of cases and lasts for longer than 24 hours.29 Fever (usually < 102°F), leukocytosis, nausea, vomiting, and changes in bowel function may also be present.1,30,31 Approximately 50% of patients report constipation in diverticular disease; 20% to 35% report diarrhea.5
Patients may also report dysuria, secondary to irritation of the bladder by an inflamed segment of colon.3,17 Patients may report fecaluria, pneumaturia, or pyuria, which indicate a colovesical fistula.1 Passage of feces or flatus through the vagina indicates a colovaginal fistula.
The differential diagnosis of diverticulitis is listed in Table 2.17
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PHYSICAL EXAMINATION
Physical examination in diverticulitis will almost always elicit tenderness to palpation over the area of inflammation, typically in the left lower quadrant. This is due to irritation of the peritoneum.3 A palpable mass may be present in as many as 20% of patients if an abscess is present. Bowel sounds may be hypoactive or hyperactive if there is a bowel obstruction.17 In cases of frank bowel-wall perforation, patients can present with peritoneal signs of rigidity, guarding, and rebound tenderness.3,31 Tachycardia, hypotension, and shock are rare but possible findings. Digital rectal examination may reveal tenderness or a mass if a pelvic abscess is present.17,31
DIAGNOSTICS
The diagnosis of acute diverticulitis can often be made clinically, based on the history and physical examination. Because clinical diagnosis can be inaccurate in as many as 68% of cases, however, laboratory testing and imaging play an important role in diagnosis.3
Continue to: Clinical laboratory studies
