NEJM Clinical Pearls
Diverticulosis: Low Fiber, Constipation, and NSAIDs
The cause of colonic diverticular disease has not yet been conclusively established. Epidemiologic studies have demonstrated associations between diverticulosis and diets that are low in dietary fiber and high in refined carbohydrates. Other factors that have been associated with an increased risk of diverticular disease include physical inactivity, constipation, obesity, smoking, and treatment with nonsteroidal antiinflammatory drugs.
The clinical manifestations of acute colonic diverticulitis vary with the extent of the disease process. In classic cases, patients report obstipation and abdominal pain that localizes to the left lower quadrant. An abdominal fullness or perirectal fullness, or “mass effect,” may be apparent. Stool guaiac testing may be trace-positive. A low-grade fever is common, as is leukocytosis. Computed tomography (CT) is recommended as the initial radiologic examination.
Morning Report Questions
Q: What is the recommended treatment for a patient suspected of suffering from acute diverticulitis?
A: The decision to hospitalize a patient for diverticulitis depends on the patient's clinical status. For most patients (i.e., immunocompetent patients who have a mild attack and can tolerate oral intake), outpatient therapy is reasonable. This involves 7 to 10 days of oral broad-spectrum antimicrobial therapy, including coverage against anaerobic microorganisms. A combination of ciprofloxacin and metronidazole is often used, but many other combinations are effective. Hospitalization is indicated if the patient is unable to tolerate oral intake or has pain severe enough to require narcotic analgesia or if symptoms fail to improve despite adequate outpatient therapy. Hospitalized patients are usually made NPO (nothing by mouth) and may be candidates for possible nasogastric tube placement if there is evidence of obstruction or ileus.
Q: Is colonoscopy or sigmoidoscopy recommended during an acute diverticulitis attack?
A: Colonoscopy and sigmoidoscopy are typically avoided when acute diverticulitis is suspected because of the risk of perforation or other exacerbation of the disease process. Expert opinion favors performing these tests when the acute process has resolved, usually after approximately 6 weeks, to rule out the presence of other diseases, such as cancer and inflammatory bowel disease.