Management of Complicated Diverticulitis

CT SCAN

This has revolutionized the management of diverticulitis because of its high sensitivity and specificity in confirming the diagnosis and identifying those patients who are candidates for therapeutic percutaneous drainage. CT scanning also excludes other causes of left lower abdominal quadrant pain (e.g., leaking abdominal aortic aneurysm or an ovarian abscess) but is not reliable in differentiating acute diverticulitis from colon malignancy. Table 2 depicts a grading system that subdivides diverticulitis based on the extent of disease. The traditionally used Hinchey classification was developed before routine CT scanning, and we have modified it slightly to reflect contemporary management. Grade IA (phlegmon, no abscess) and grade IB (phlegmon with abscess G4 cm) are treated with intravenous antibiotics. There are a variety of choices, but the agent(s) need to provide good coverage for aerobic gram-negative rods and anaerobes (e.g., piperacillin/tazobactam). Those who respond with resolution of pain, fever, and leukocytosis are started on an oral diet and converted over to oral antibiotics, again covering aerobic gram-negative rods and anaerobes (e.g., Levaquin and Flagyl) for a total of 14 days of antibiotics. They can be discharged home (see K. Home). Those who do not respond are taken to the OR for definitive resection (see J. Definitive Resection).