It occurs due to increased intraluminal pressure, usually due to low fiber

diet causing smaller stool volume, so then the increased pressure would
result to muscular hypertrophy and development of segmentation. And
because po sa segmentation, yung pressure instead na directed distally, it
becomes directed to the colonic wall causing diverticulum po and
diverticulosis (presentation is bleeding). And if there is inflammation or
infection, then it would result in diverticulitis (presentation is perforation).

Colon has a vasa recta which enters the intestine in the muscularis mucosa
layer… point where diverticulum can start. Hypertrophy of colon wall
muscle plus narrow lumen. High pressure zone causing herniation.

Fecal matter in the outpouching .. infection and diverticulitis

CLINICAL PRESENTATION
● LLQ painn, fever, change in bowel habits, anorexiaa, urinary urgency
● Hematochezia → kung saan yung weakness nandoon yung walang
muscle, tapos doon nageenter artery and vein.. Close relation to the
neck of diverticuulum causes erosion of bv??

DIAGNOSIS
● Abdominal Xray
○ Obstruction or free intraperitoneal air
● CT Scan
○ Fat stranding → inflammation
● Ultrasound
○ Weakness → presence of air; difficult to identify structures
● Endoscopy
○ Will cause distension →
● Leukocytosis

TYPES
● Complicated - perforation, fistula, abscess, stricture, obstruction
 ○ Perforation will occur then magkakaroon ng abscess, kapag
gumaling yung nana, magkaka stricture, tapos
magkakaobstruction
■ Free perforation → kapag di nacontain yung abscess
■ Fistula → Kapag nabutas yung abscess sa katabing
organ
○ Colovesical → close proximity of sigmoid to bladder
○ In asia – most common site ascending colon (colon-SI)
● Uncomplicated

Note:
Ileus → Due to adhesions or scar tissue or due to boswel obstruction
Peritonitis → Is not always an indication for surgery, baka kasi pagopen
mo hinchey 1 or 2 lang

MANAGEMENT
● Outpatient Treatment
○ Co-amoxiclav 625 mg; kapag healthy they opt not to give
antibiotics
 ○ Colonoscopy in 6-8 wks
○ Diet → no evidence for dietary restrictions; modified diet..
Limited to liquid diet then reassess in 2-3 days then go na to
soft diet
○ If patient is immunocompromised (<5 , >65 yo) HIV, steroids,
cancer → Still opt for ANTIBIOTICS
○
● Inpatient Treatment
○ IV antibiotics
■ Fluoroquinolones
■ Carbapenems
■ Amoniglycosides
● Walang anaerobe coverage, gram neg lang
■ Cephalosporins (dalawa lang may anaerobic coverage)
● Cefoxitin (ito lang nasa pinas)
■ Penicillin-Based → Coamox
■ Combination: Metronidazole + something for gram
negative
○ Intravenous fluids
■ Plain lactated ringers kapag GI yung problem
○ Pain medications
■ Doc acuna do not give maximal pain meds kasi gauge
yun kung gumagaling or not yung patient
○ Clinically responds within 2-3 days
■ Criteria for discharge
● Normalize VS
● Resolution of severe abdominal pain
● Resolution of significant leukocytosis (should be
<12,000)
● Tolerance of oral diet
○ No pain, distension, or N/V post-prandial
○ (+) bowel movement
○ Given diet for diverticulitis is low fiber para
walang tae or no residue (para sa initial
 management lang to) tapos high fiber na para
di na mag-recur
○ Failure to improve → Surgery
■ Criteria of failure of medical management
● Increased abdominal pain
● Increased/presence of leukocytosis
● Diffuse peritonitis
● Acute Uncomplicated - Medical
● Acute ComplIcated Diverticulitis - Surgical + Medical

ANTIBIOTICS
● Flora of colon → gram negative, anaerobes (80% is bacteroides,
10-15% gram neg, 5-10% gram positive)
○ Gram Negative
■ Aminogly
■ Cephalosporin
■ Flouroquinolones
■
● Metronidazole - gram neg & anaerobes
● Ciprofloxacin
● Co-amox broad spectrum

CLASSIFICATION
● 1 localized pericolic
○ Usually mesentery yung abscess
○ Imagine blood supply nasa mesentery tapos papasok sa colon
● 2 distant (retroperitoneal or pelvic)
● 3 purulent peritonitis
● 4 feculent peritonitis

7 AREAS TO SEARCH FOR OR WASH

● Subdiaphragmatic
 ○ Diaphragm kasi has a suctioning effect on the bowel; kaya
nagkakaroon ng abscess mula sa pelvis papunta sa ilalim ng
diaphragm
● Subhepatic
● Left Colonic Gutter
● Right Colonic Gutter
● Pelvis
● Interloops
● Below the falciform ligament

COMPLICATIONS

● Obstruction →
● Fistula → Bladder > Vagina > Small Bowel > Uterus
○ Colovesical → recurrent UTI (twice a year), pneumaturia or may
air bubbles or air during urination, feculent smell of urine/
discharge; warrants immediate operation because of
pyelonephritis
● Bleeding
○ Most common cause of overt GI bleeding
○ Red streaked stools but not as bright as the bleeding in
hemorrhoids (arterialized bleeding - bright red)

Symptomatic Uncomplicated Diverticulitis

● Chronic abdominal pain without

How to Evaluate?
● History → LLQ pain, fever
● PE → Abdominal Guarding, Rebound Tenderness; for the signs of
peritonitis
● Laboratory → CBC, Urinalysis, Abdominal Radiographs
○ CRP: Complicated if >150
 ● Imaging → CT SCAN
○ Gold standard: diagnose and assess severity
○ Findings: colonic wall thickening, abscess, extraluminal gas or
fluid, fat stranding
● Imaging for CT scan contraindicated patients such as pregnant
patients or patients allergic to contrast
○ Transvaginal Ultrasound → can r/o other causes of pelvic pain
but can miss complicated diverticulitis
○ MRI to differentiate neoplasia from diverticulitis

Management
Treatment Without Antibiotics?
● Yes, in uncomplicated diverticulitis!
● Group of co-amox (12 days recovery) and group of just observation
(14 days recovery)

Note: Latest recommendation of American Society of Diabetes → on fire

kasi puro gamot Metformin and Insulin lang, walang dietary management
when it can actually reverse diabetes??

Non-operative Treatment May Include Antibiotics!!

● IV antibiotics → Short course (4days) vs Long course (7days) → no
difference in effectiveness
● Co-amox was used → covers gram positive and negative and some
anaerobes
● Note (Dr. Acuna): Sultamicillin → covers gram positive and negative
and most anaerobes
● Antibiotic treatment alone for abscesses <3cm is successful
● But for more than 3 cm → consider percutaneous drainage

Medications → Mesalamine, Probiotics, Rifaxamine

When to do Colonoscopy?
● After resolution of acute complicated diverticulitis
 ● Do 6 weeks after acute episode; Colonoscopy need insufflation which
will push the fecal matter more → increased perforation
● Purpose: Exclude malignancy → Increased risk of harboring
malignancy

Elective Surgery for Acute Diverticulitis

● Elective resection not routine in those who have successful
nonoperative tx of diverticular abscess but suggested in higher risk
abscess like larger abscess
● Young age (<50 yo) at presentation is not recommended for elective
resection; because age does not increase the risk of more
complicated recurrences
● Decision to recommend elective sigmoid colectomy after recovery
from uncomplicated acute diverticulitis should be individualized

Emergency Surgery for Acute Diverticulitis

● Typically advised when there is diffused or multiquadrant peritonitis or
failure of non-operative management of acute diverticulitis fails
● Resect colon segment → Perform primary anastomosis with or
without loop ileostomy OR Hartmann procedure; depending on
surgeon’s preference
○ No statistically significant mortality or morbidity between
primary anastomosis or hartmann
○ But hartmann procedure has higher morbidity for hartmann
reversal
○ Parameters favoring Hartmann:
■ Hemodynamic instability
■ Acidosis
■ Organ Failure
■ Immunosuppression
■ Older
■ Poor bowel function and sphincter tone
Laparoscopic Lavage
● Not recommended in feculent peritonitis (hinchey IV) but is usually
applied to purulent peritonitis (hinchey 3) but colectomy is still
preferred!
● Laparoscopic lavage is associated with higher rates of secondary
intervention in comparison with colectomy because of possible
abscess or unresolved septic foci; most have colectomy within 1 year
of laparoscopic lavage
● So, colectomy is advised for Hinchey 3 and 4

Extent of Elective Resection

● Entire sigmoid colon with margins of healthy colon and rectum
● Proximal Resection Margin → soft, pliable iwhtouh gross
inflammation; not necessary to resect all proximal
● Distal Resection Margin → should be on healthy rectum because
anastomosis in distal sigmoid has a higher risk of recurrence
● Tension free → Mobilize splenic flexure or rectum

Open or Laparoscopic?
● If expert then laparoscopic → shorter operative time
● No significant difference on the days of return of BM, hospital day

SUMMARY
● Abdominal Pain
○ Asian → right sided pain (because most common location is
distal ileum)
○ American → left sided pain
● Best imaging is CT Scan
● Colonoscopy not recommended in acute inflammation
● Advise medical management on uncomplicated acute diverticulitis
● For stage 1 and 2 → managed with broad spectrum antibiotics and/or
percutaneous drainage (recommended for >3cm; but can also be
done if <3cm)
● For stage 3 and 4 → managed with colectomy than laparoscopic
lavage
○ Stage 3 → Colectomy plus primary anastomosis
○ Stage 4 → Colectomy + hartmann procedure