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INTRODUCTION

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Diverticulitis is a common GI disorder that occurs when small herniations through the wall of the colon, or diverticula, become inflamed or infected.

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CLINICAL FEATURES

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Classically, diverticulitis presents with left lower abdominal pain, fever, and leukocytosis. The most common symptom is a steady, deep discomfort in the left lower quadrant of the abdomen. Pain may be constant or intermittent, with associated symptoms of change in bowel habits (constipation or diarrhea), nausea, vomiting, and anorexia. Urinary tract symptoms are less common. Patients with a redundant sigmoid colon, of Asian descent, or with right-sided disease may complain of pain in the suprapubic area or right lower quadrant. The presentation can mimic other diseases, such as appendicitis.

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Patients have a low-grade fever, but the temperature may be higher in patients with generalized peritonitis and in those with an abscess. Physical findings range from mild abdominal tenderness to severe pain, obstruction, and peritonitis. Occult blood may be present in the stool.

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DIAGNOSIS AND DIFFERENTIAL

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The differential diagnosis includes acute appendicitis, colitis (ischemic or infectious), inflammatory bowel disease (Crohn’s disease or ulcerative colitis), colon cancer, irritable bowel syndrome, pseudomembranous colitis, epiploic appendagitis, gallbladder disease, incarcerated hernia, mesenteric infarction, complicated ulcer disease, peritonitis, obstruction, ovarian torsion, ectopic pregnancy, ovarian cyst or mass, pelvic inflammatory disease, sarcoidosis, collagen vascular disease, cystitis, kidney stone, renal pathology, and pancreatic disease.

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Diverticulitis can be diagnosed by clinical history and examination alone. In stable patients with past similar acute presentations, no further diagnostic evaluation is necessary unless the patient fails to improve with conservative medical treatment. If a patient does not have a prior diagnosis or the current episode is different from past episodes, diagnostic imaging should be performed to rule out other intraabdominal pathology and evaluate for complications. CT scan is the preferred imaging modality for its ability to evaluate the severity of disease and the presence of complications. CT with IV and oral contrast has documented sensitivities of 97% and specificities approaching 100%. Compression ultrasound is operator dependent and has been shown to have sensitivity and specificity greater than 80% with experienced operators. Laboratory tests, such as a CBC, liver function tests, and urinalysis, are not diagnostic but may help exclude other diagnoses.

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EMERGENCY DEPARTMENT CARE AND DISPOSITION

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ED care begins with fluid and electrolyte replacement, pain, and nausea control.

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  1. Ill-appearing patients, those with uncontrolled pain, vomiting, peritoneal signs, signs of systemic infection, comorbidities, or immunosuppression, and those with complicated diverticulitis (e.g., phlegmon, abscess, obstruction, fistula, or perforation), require admission and surgical consultation.

  2. Uncomplicated diverticulitis is managed with oral antibiotics and a liquid diet, although recent data suggests that antibiotics may not be required in uncomplicated diverticulitis.

  3. Outpatients should follow up with a gastroenterology specialist for an outpatient colonoscopy in 6 weeks if they show improvement. Patients with worsening of their ...

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