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Overview

Clinical Features

Staging

Several staging schemes available - the most useful is clinical staging by Hinchey's classification (as it can help dictate surgical intervention):

Initial Management

  1. Check the WCC, HB & Amylase, other blood tests are only needed if medically indicated
  2. Dipstick the urine and send some for culture
  3. Place the patient on free fluids, no solid food, but enteral supplements can be used
  4. Start IV Cefuroxime 750mg TDS + IV Metronidazole 500mg TDS
  5. Get a plain AXR
  6. Consider an early CT

Continuing Management

  1. Patient can start ‘low residue’ diet as pain starts to settle and then goes onto ‘high residue’  (i.e. high fibre) when completely settled
  2. Consider USS pelvis in women
  3. Patients not settling after 48hrs need a CT abdo & Pelvis
  4. Bowel needs to be imaged preferably by colonoscopy once the pain has settled.
  5. The timing and need for surgical intervention is complicated and shouldbe discussed with the patients and a consultant colorectal surgeon:
    • Hinchey stage I may be treated medically without surgical intervention
    • Hinchey stage II may be treated by radiological drainage and medical treatment
    • Hinchey stage III/IV disease almost always requires surgical intervention
  6. Elective surgery previously recommended in those who had 2 or more episodes of diverticulitis successfully treated medically; however, recent data call this practice into question when the patient is otherwise healthy - this very much depends on the patient and requires in-depth discussion and should be made on a case-by-case basis.
  7. A 2-stage surgical approach is the most common & safest surgical procedure:
    • Hartmann's procedure with reversal 3-6 months later. This is the preferred & recomended approach in patients with faecal peritonitisand sepsis.
    • The alternative is resection of the diseased colon, primary anastomosis and proximal diverting stoma - this is for experienced surgeons only who can make the correct decision to perform this based on intr-operative findings - it is not recomended in faecal peritonitis
  8. There is no role for lavage and drainage as morbidity and mortality are significantly higher