Diverticulitis


SYMPTOMS

EXAM

DIFFERENTIAL

Acute appendicitis
Colitis—ischemic or infectious
Inflammatory bowel disease (Crohn disease, ulcerative colitis)
Colon cancer
Irritable bowel syndrome
Pseudomembranous colitis
Epiploic appendagitis
Gallbladder disease
Incarcerated hernia
Mesenteric infarction
Complicated ulcer disease
Peritonitis
Obstruction
Ovarian torsion
Ectopic pregnancy
Ovarian cyst or mass
Pelvic inflammatory disease
Cystitis
Kidney stone
Renal pathology
Pancreatic disease

 

DIAGNOSIS

TREATMENT

Outpatient or Inpatient Status Antibiotic and Dosage (adjust dosages based on renal function)
Outpatient, 7–14 d oral medication Metronidazole, 500 milligrams PO every 8 h
and 
Ciprofloxacin, 500 milligrams PO every 12 h
or 
Levofloxacin, 500 milligrams PO once a day
or 
Clindamycin, 300 milligrams PO every 6 h
or 
Trimethoprim-sulfamethoxazole DS, one tablet PO every 12 h
Amoxicillin-clavulanate, 875 milligrams PO every 12 h
Moxifloxacin, 400 milligrams PO once a day
Inpatient, moderate to severe disease Ampicillin-sulbactam, 3 grams IV every 6 h
or 
Piperacillin-tazobactam, 3.35 grams IV every 6 h, or 4.5 grams IV every 8 h
or 
Ertapenem, 1 gram IV once a day
or 
Ticarcillin-clavulanate, 3.1 grams IV every 6 h
or 
Moxifloxacin, 400 milligrams IV once a day
Metronidazole, 500 milligrams IV every 6 h
and 
Levofloxacin, 750 milligrams IV once a day
or 
Ciprofloxacin, 400 milligrams IV every 12 h
Intensive care unit patient, very severe disease Imipenem, 500 milligrams IV every 6 h
or 
Meropenem, 1 gram IV every 8 h
or 
Doripenem, 500 milligrams IV every 8 h (each infusion given over 1 h)
Ampicillin, 2 grams IV every 6 h
and 
Metronidazole, 500 milligrams IV every 6 h
and 
Gentamicin, 2 milligrams/kg IV as initial dose, then 1.7 milligrams/kg every 8 h

 

COMPLICATION


DISPOSITION AND FOLLOW UP

Admit Orders: Diverticulitis

1. Admit to:

2. Diagnosis: Diverticulitis

3. Condition:

4. Vital Signs: qid. Call physician if BP systolic >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C.

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs.

7. Diet: NPO. Advance to clear liquids as tolerated.

8. IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at 125 cc/hr. NG tube at low intermittent suction (if obstructed).

9. Special Medications:

Inpatient Regimen:
 

-Metronidazole (Flagyl) 500 mg q8h 
AND

Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300 mg IV q12h  [STOP if C.Diff positive]
OR

-Amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily.
 

Outpatient Regimen:

-Metronidazole (Flagyl) 500 mg PO q6hAND

Ciprofloxacin (Cipro) 500 mg PO bid.
 

10. Symptomatic Medications:

- Morphine sulfate 5-10 mg IV push prn pain.

-Zolpidem (Ambien) 5-10 mg qhs PO prn insomnia.
 

11. Extras: Acute abdomen series, CXR PA and LAT, ECG, CT of abdomen, ultrasound, surgery and GI consults.

12. Labs: CBC with differential, CMP, amylase, lipase, blood cultures x 2, drug levels peak and trough 3rd dose. UA, urine C&S.