Diverticulitis

Involves obstruction of a diverticula, leading to inflammation and occasional perforation of the bowel.

Initial management is from a systematic assessment and initial management as per CCrISP protocol.

Investigations that should be arranged include FBE, UEC, CRP. A portal venous phase CT scan should be arranged to confirm the diagnosis and assess severity.

Treatment algorithm

Well and Hinchey < 2	Antibiotics
Well and Hinchey 2	Perc drainage
Unwell	Operation

1. Diverticulitis classification diverticulitis

1.1. Front

What is the hinchey classification for diverticulitis?

1.2. Back

Modified Hinchey classification

1a	Pericolic phlegmon and inflammation, no fluid collection
1b	Pericolonic abscess < 4cm
2	Pelvic or interloop abscess OR abscess > 4cm
3	Purulent peritonitis
4	Faeculent peritonitis

1.3. Interview interview diverticulitis

1.3.1. Front

You are asked by the emergency department to urgently review a 78 year old female who has was BIBA with generalised abdominal pain. She has global peritonism and a CT scan that shows sigmoid diverticulitis with free gas and fluid in the abdomen. While you are assessing her, she becomes more drowsy and the her blood pressure is 78/50 with a heart rate of 80. Her past medical history include rapid AF on rate control, but on aspirin alone.

How will you manage this patient?

1.3.2. Back

This is a scenario of a critically unwell patient who is deteriorating during assessment. I would call for help, some EDs allow MET calls, otherwise I'd make sure this patient was in a resus bay with senior ED clinicians assisting. I would manage this patient as per CCriSP principles, ensuring airway and breathing and circulation were secure. I would make sure she had oxygen, and two large bore IV cannula with crystalloid resuscitation fluid. I'd make sure she is given broad spectrum IV antibiotics. Cetriaxone and metronidazole are indicated in GI perforation, but given her critical illness, I'd want to cover with tazocin for extra enterococcal cover.

While instigating this initial resuscitation I'd be updating my fellow and consultant. To control her sepsis, she needs an urgent Hartmanns procedure and washout.

Critically, if she was not cognitively impaired from her illness, I'd clarify her values and preferences, as well as document her goals of care. If she was too obtunded, I'd see if there was an advanced care directive and clarify goals with her next of kin.

She would likely need postoperative HDU or ICU. I would discuss her case with the ICU team.