Management of Complicated Diverticulitis

Abdominal pain is the primary presenting symptom of diverticulitis. It is typically located in the left lower quadrant; however, a redundant sigmoid colon can reach the right lower quadrant and mimic appendicitis. Localized peritoneal irritation can result in guarding and rebound tenderness. Free perforation often presents as frank peritonitis. Fever and leukocytosis are frequently present and assist in making the clinical diagnosis. Nausea and vomiting are the most notable symptoms when a stricture results in an obstruction. During the initial clinical assessment, SIRS severity (Table 1), presence of peritonitis, and signs of organ dysfunction drive early decision making. Patients with severe sepsis/septic shock should have adequate intravenous access obtained (at least two large-bore lines), be administered a bolus of crystalloids (generally 20 mL/kg), and be given broad spectrum antibiotics.¹⁷  A flat plate and an upright roentgenogram of the abdomen are good screening tools to identify evidence of obstruction and/or free air. Initial laboratory testing should include a complete blood cell count and electrolyte, lactate, and coagulation profile (if surgery is anticipated).