eMedicine Specialties > Gastroenterology > Colon

Diverticulitis

Minh Chau T Nguyen, MD, Assistant Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center; Physician Specialist, Department of Ambulatory Medicine, Olive View-University of California at Los Angeles Medical Center
Yuvrajsinh Narendrasinh Chudasama, MD, Staff Physician, Department of Internal Medicine, University of California at Los Angeles, Olive View Medical Center; Stanley K Dea, MD, Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology; Andrea Cooperman, MD, Associate Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center

Updated: Jun 30, 2008

Introduction

Pathophysiology

Diverticula are small mucosal herniations protruding through the intestinal layers and the smooth muscle along the natural openings created by the vasa recta or nutrient vessels in the wall of the colon. These herniations create small pouches lined solely by mucosa. Diverticula can occur anywhere in the gastrointestinal tract but are usually observed in the colon. The sigmoid colon has the highest intraluminal pressures and is most commonly affected. Diverticulosis is defined as the condition of having uninflamed diverticula. The cause of diverticulosis is not yet conclusive, but it appears to be associated with a low-fiber diet, constipation, and obesity.

Diverticulitis is defined as an inflammation of one or more diverticula. Its pathogenesis remains unclear.  Fecal material or undigested food particles may collect in a diverticulum, causing obstruction. This obstruction may result in distension of the diverticula secondary to mucous secretion and overgrowth of normal colonic bacteria. Vascular compromise and subsequent microperforation or macroperforation then ensue. Alternatively, some believe that increased intraluminal pressure or inspissated food particles cause erosion of the diverticular wall, resulting in inflammation, focal necrosis, and perforation. The disease is frequently mild when pericolic fat and mesentery wall off a small perforation. However, larger perforations and more extensive disease lead to abscess formation and, rarely, intestinal rupture or peritonitis.

Fistula formation is a complication of diverticulitis. Fistulas to adjacent organs and the skin may develop, especially in the presence of an abscess. In men, colovesicular fistulas are the most common. In women, the uterus is interposed between the colon and the bladder, and this complication is only seen following a hysterectomy. The uterus precludes fistula formation from the sigmoid colon to the urinary bladder. However, colovaginal and colocutaneous fistulas can form but are uncommon.

Recurrent attacks of diverticulitis can result in the formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.

Frequency

United States

Asymptomatic diverticulosis is a common condition. The incidence of diverticulosis increases with age, from less than 5% before age 40 years to greater than 65% by age 85 years.

Diverticulitis appears to be more common in patients with the largest number of diverticula; 15-20% of those with diverticulosis develop diverticulitis. While diverticulitis is generally considered a disease of the elderly population, as many as 20% of patients with diverticulitis are younger than 50 years.

International

Diverticulosis occurs more frequently in Western countries and industrialized societies. As it is less common in underdeveloped countries, diverticulitis is also less common. The reason is unclear but presumably secondary to lifestyle and dietary factors. In fact, after adopting a more Western lifestyle, the prevalence of diverticulosis has increased in Japan.  For unclear reasons, right-sided disease is more common in Asian people, accounting for as many as 75% of cases of diverticulitis in that group. 

Mortality/Morbidity

Of patients with diverticulosis, 80-85% remain asymptomatic. Approximately 5% develop diverticulitis; 15-25% of those with diverticulitis develop complications leading to surgery. These complications include abscess formation, intestinal rupture, peritonitis, and fistula formation. 

Diverticulitis may be a more severe illness in patients who are immunocompromised, in patients with significant comorbid conditions, and in those taking anti-inflammatory medications.  

• Patients with diverticulitis who are managed conservatively (ie, do not receive surgery) have a recurrence rate of 20-35%. 
• In one study of 252 patients, a recurrence rate of 50% was reported after 7 years. The rate of surgery in these patients was 8% at 7 years and rose to 14% by 13 years.  Recurrence rates after surgical resection range from 1-3%. The mortality rate from complications in patients with recurrent disease in this small study was 1%.
• Another study of 337 patients hospitalized for complicated diverticulitis revealed an association of perforation and mortality in those with no prior history of diverticulitis.  Of these patients with complicated diverticulitis, 53% presented on a first event.
• These morbidity and mortality data, as well as recurrence rates, are based on a retrospective review of relatively short-term data.

Race

Genetics are believed to play a role, in addition to dietary factors. Left-sided diverticula predominate in the United States. Asians, including Asian Americans, have a predominance of right-sided diverticula.

Sex

Prevalence is similar in men and women.

Age

Diverticular disease increases in incidence with age, reaching a prevalence of greater than 65% in those older than 85 years. The mean age at presentation with diverticulitis appears to be about 60 years.

Clinical

History

The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint and occurs in 70% of patients.  Pain is often described as crampy and may be associated with a change in bowel habits. Other symptoms include nausea and vomiting, constipation, diarrhea, flatulence, and bloating.  Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.   

A microperforation, most likely walled off by adjacent structures, may present with no systemic signs of illness or infection. On the other hand, disease may progress from a localized and walled-off process to one with peridiverticular inflammatory phlegmon and localized abscess. Systemic signs of infection (eg, fever) then develop. Because diverticula and, hence, diverticulitis can develop anywhere in the gastrointestinal tract, symptoms may mimic multiple conditions.

• Diverticulitis in the right colon or in a redundant sigmoid colon may be mistaken for acute appendicitis. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similar to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecological process.
• More severe diverticulitis is often accompanied by anorexia, nausea, and vomiting. Typically, the pain is localized and severe and present for several days prior to presentation. Altered bowel habits, especially constipation, are reported by most patients. A small percentage of patients may complain of urinary symptoms, such as dysuria, urgency, and frequency, due to inflammation adjacent to urinary tract structures.
• Macroperforation with spillage of colonic contents into the peritoneum leads to generalized abdominal pain and peritonitis.
• Leg pain possibly associated with a thigh abscess and leg emphysema secondary to retroperitoneal perforation from diverticulitis have been reported.

Physical

Diverticulitis can present with a range of physical findings, mirroring the severity of the inflammation and the presence of complications.

• In simple diverticulitis, localized abdominal tenderness in the area of the affected diverticula and fever are common findings. Left lower quadrant tenderness is the most common physical finding, as most diverticula occur in the sigmoid colon. Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-sided diverticulitis. 
• In complicated diverticulitis with abscess formation, a tender palpable mass may be felt on physical examination. In fact, 20% of cases present with a palpable mass on abdominal, pelvic, or rectal examination. Peritonitis due to free perforation results in generalized tenderness with rebound and guarding on abdominal examination. The abdomen may be distended and tympanic to percussion. Bowel sounds can be diminished or absent.
• Elderly patients and some patients taking corticosteroids may have unremarkable findings on physical examination even in the presence of severe diverticulitis. Such patients must be approached with a high index of suspicion to avoid a delay in establishing the correct diagnosis.
• If a fistula forms, the findings vary depending on the type of fistula. Colovesicular fistulas may present with urinary tract symptoms, such as suprapubic, flank, or costovertebral angle tenderness. Fecaluria can also be observed. Female patients with colovaginal fistulas may present with a purulent vaginal discharge.

Causes

See Pathophysiology.

Differential Diagnoses

Workup

Laboratory Studies

• The diagnosis of acute diverticulitis can usually be made on the basis of history and physical examination. Laboratory tests may be of help when the diagnosis is in question.
• A hemogram may reveal leukocytosis and a left shift, indicating infection. However, the absence of leukocytosis does not rule out diverticulitis, as 20-40% of patients have a normal white blood cell count. This is particularly true in patients who are immunocompromised, in elderly patients, and in those with less severe disease. A hemoglobin level is important when the patient reports hematochezia.
• Chemistries may be helpful in the patient who is vomiting or has diarrhea to assess electrolyte abnormalities. Renal function is assessed prior to the administration of most intravenous contrast material.
• Liver tests and lipase may help to exclude other causes of abdominal pain.
• If a colovesicular fistula is suspected, urinalysis may reveal red or white blood cells. However, inflammation and infection due to diverticulitis adjacent to the ureters or the bladder may be the source of the cells. A urine culture may confirm sterile pyuria due to inflammation versus polymicrobial infection in the case of a fistula.
• Blood cultures should be obtained prior to the administration of empiric parenteral antimicrobial therapy in patients who are severely ill or in those with complicated disease.
• A pregnancy test must be performed in any female of childbearing age who presents with abdominal pain to rule out ectopic pregnancy, as well as prior to radiologic studies and before administering certain antibiotics to protect a viable fetus.

Imaging Studies

• The diagnosis of diverticulitis can be made on clinical grounds, but a CT scan of the abdomen is considered the best imaging method to confirm the diagnosis. 
• CT scans are preferred over intraluminal examinations (eg, barium enema), since the bulk of inflammation is extraluminal. CT scans can help assess disease severity, the presence of complications, and clinical staging. In the acute setting, CT scans are safer than contrast studies. Sensitivity and specificity, especially with helical CT and colonic contrast, can be as high as 97%.   
• Possible CT findings include the following: pericolic fat stranding due to inflammation, colonic diverticula, bowel wall thickening, soft tissue inflammatory masses, phlegmon, and abscesses. Peritonitis, fistula formation, and obstruction can also be assessed. It can be used to guide percutaneous drainage of an abscess.
• Contrast enema is not the imaging modality of choice during an acute episode of abdominal pain and should only be considered in mild-to-moderate uncomplicated cases of diverticulitis when the diagnosis is in doubt. A water-soluble contrast should be used, as leakage of barium into the peritoneum would be catastrophic.
• Plain radiograph films are not helpful in making the diagnosis of diverticulitis. However, plain abdominal radiograph series with supine and upright films can demonstrate bowel obstruction or ileus. If free air is present, this can indicate bowel perforation.

Procedures

• Endoscopy is not recommended in the acute setting given the risk of worsening diverticulitis and bowel perforation.  After the diverticulitis has subsided, colonoscopy can be used to evaluate the extent of diverticulosis or to rule out a malignancy masquerading as a benign postinflammatory stricture.

Staging

Several staging schemes have been proposed based on clinical findings, extent on imaging studies, and the presence of complications.  Probably, the simplest method is to differentiate among asymptomatic diverticulosis, uncomplicated diverticulitis, and complicated diverticulitis.

Clinical staging by Hinchey's classification is geared toward choosing the proper surgical procedure when diverticulitis is complicated, as follows:

• Stage I disease - Small or confined pericolic or mesenteric abscess
• Stage II disease - Large abscess, often confined to the pelvis
• Stage III disease - Perforated diverticulitis causing generalized purulent peritonitis
• Stage IV disease - Rupture of diverticula into the peritoneal cavity with fecal contamination causing generalized fecal peritonitis

Treatment

Medical Care

The approach to the treatment of diverticulitis can be broadly classified into either uncomplicated disease or complicated disease, with a few other special considerations to take into account. Acute uncomplicated diverticulitis is successfully treated in 70-100% of patients with conservative management. 

• Acute diverticulitis tends to be more severe in very elderly people and in patients who are immunocompromised or who have debilitating comorbid conditions, such as diabetes and renal failure.
• Patients with mild diverticulitis, typically with Hinchey stage I disease, can be started on an outpatient treatment regimen. This consists of a clear liquid diet and 7-10 days of oral broad-spectrum antimicrobial therapy, which covers anaerobic microorganisms, such as Bacteroides fragilis and Peptostreptococcus and Clostridium organisms , as well as aerobic microorganisms, such as Escherichia coli and Klebsiella, Proteus, Streptococcus, and Enterobacter organisms. Single and multiple antibiotic regimens are equally effective as long as both groups of organisms are covered.  
  • One typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate monotherapy for outpatient treatment of uncomplicated diverticulitis. Amoxicillin/clavulanic acid monotherapy is acceptable as well.
  • Patients should be instructed to be on a clear liquid diet only and can advance the diet slowly as tolerated after clinical improvement, which usually occurs within 2-3 days. 
• Hospitalization is required with evidence of severe diverticulitis, such as systemic signs of infection or peritonitis. Patients who are unable to tolerate oral hydration, who fail outpatient therapy (ie, persistent or increasing fever, pain, or leukocytosis after 2-3 d), who are immunocompromised, or who have comorbidities may also require hospitalization. Pain may be severe enough to require parenteral narcotic analgesia. 
  • Initiate bowel rest and intravenous fluid hydration. Start broad-spectrum intravenous antibiotic coverage until culture results, if obtained, are available.
  • Monotherapy with beta-lactamase inhibiting antibiotics or carbapenems provides broad antibacterial coverage and is appropriate for patients who are moderately ill and require admission. Such antibiotics include the following: piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, imipenem, or meropenem.
  • Multiple drug regimens are also appropriate options in the hospital setting and may consist of metronidazole and a third-generation cephalosporin or a fluoroquinolone. Such antibiotics include the following: ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin.  Previously, gentamicin was recommended as part of a multiple drug regimen. Although it is still a reasonable choice, substitution with a third-generation cephalosporin or a fluoroquinolone has been advocated to avoid the risk of aminoglycoside nephrotoxicity.
  • When severe penicillin allergy is a concern, tigecycline is a good choice for monotherapy.
  • For patients who are immunocompromised, imipenem or meropenem may be preferred over ertapenem for better enterococcal and pseudomonal coverage.
  • Pain management is important. Morphine is acceptable for pain control and is preferable over meperidine given the adverse effects associated with meperidine. Although early recommendations for pain management favored meperidine based on a theoretical risk of affecting bowel tone and sphincters, randomized prospective studies comparing the narcotic options are not available.  Use of nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of colon perforation and should be avoided whenever possible.
  • Within 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis should begin to resolve. The patient can then be started on a clear liquid diet and advanced as tolerated. If tolerating oral intake and clinically stable, the patient can be discharged to complete a 7- to 10-day course of oral antibiotic therapy.
  • If fever and leukocytosis do not resolve after 2-3 days of treatment or if serial examinations reveal worsening signs or new peritoneal findings, a repeat CT scan of the abdomen is advisable to rule out an abdominal abscess or other complications.
  • If a patient is found to have a peridiverticular abscess that measures more than 4 cm in diameter (Hinchey stage II disease), a CT–guided percutaneous drainage is indicated. This usually leads to a prompt (<72 h) reduction in pain, fever, and leukocytosis. Percutaneous drainage is also beneficial in that it may allow for elective surgery rather than emergency surgery and increase the likelihood of a successful 1-stage procedure.
  • For abscess cavities containing gross fecal material or when there is perforation, early surgical intervention is required.
• Once the acute episode has resolved, the patient may advance diet as tolerated and then maintain a lifelong high-fiber diet. Colonoscopy or, alternatively, barium enema with flexible sigmoidoscopy should be done after resolution of an initial episode (typically 2-6 wk after recovery) to exclude other diagnoses, such as cancer, ischemia, and inflammatory bowel disease.

Surgical Care

About 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease that requires surgery.

• The classic surgical indications include some features characteristic of Hinchey stage III or IV disease and are as follows:
  • Free-air perforation with fecal peritonitis
  • Suppurative peritonitis secondary to a ruptured abscess
  • Uncontrolled sepsis
  • Abdominal or pelvic abscess (unless CT-guided aspiration is possible)
  • Fistula formation
  • Inability to rule out carcinoma
  • Intestinal obstruction
  • Failing medical therapy
  • Immunocompromised status
  • Extremes of age
  • Recurrent episodes of acute diverticulitis (Elective surgery was previously recommended in any patient who had 2 or more episodes of diverticulitis that were successfully treated medically; however, recent data call this practice into question when the patient is otherwise healthy.)
• Preoperative preparation with antibiotics should be given in all patients.  Single and multiple drug regimens, as discussed in Medical Care, are appropriate choices.  However, for patients with more extensive contamination, a single drug regimen (with either imipenem/cilastin or piperacillin/tazobactam) or a multiple drug regimen (with ampicillin, gentamicin, and metronidazole) may be warranted for peritonitis.  Bowel preparation is usually possible for nonemergent situations.
• The American Society of Colon and Rectal Surgeons most recent guidelines from 2006 recommend emergency surgery for patients with diffuse peritonitis or for those who fail nonoperative management. Also, patients who are immunosuppressed or immunocompromised are at an increased risk of failing medical therapy or perforation and should be approached with a lower threshold.
• A 2-stage surgical approach is the most common surgical procedure performed today for the emergency treatment of acute diverticulitis.
  • A traditional Hartmann procedure is commonly performed, which involves resection of the diseased segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a second procedure can be performed to close the rectal stump; however, this second operation can be technically difficult and is not performed in many patients. This is the preferred approach in patients with fecal peritonitis and in most cases of purulent peritonitis. 
  • An alternative to the Hartmann procedure includes resection of the diseased colon, primary anastomosis (with or without intraoperative colonic lavage), and proximal diverting stoma, either colostomy or ileostomy. The second procedure in this course would be to close the stoma. This approach is primarily used when there are relative contraindications to primary anastomosis but no purulent or feculent peritonitis and there is nonedematous bowel. The advantage is that it avoids the technically difficult second stage used in the Hartmann procedure.
  • Extensive and unnecessary dissections, which open up tissue planes to infection and increase blood loss, have no role.
• The decision to proceed with elective surgery, typically at least 6 weeks after recovery from acute diverticulitis, should be made on a case-by-case basis.  This decision should consider age and medical condition of the patient, frequency and severity of attacks, and the presence of any persistent symptoms after the acute episode. Other appropriate indications for elective colectomy include inability to exclude carcinoma, after an episode of complicated diverticulitis treated nonoperatively, or after percutaneous drainage of a diverticular abscess.
  • Regarding frequency, after one attack, about one third of patients will have a later second attack of acute diverticulitis. After a second episode, a further one third will have yet another attack. 
  • Regarding severity, most patients who present with complicated diverticulitis do so at the time of their first episode. Therefore, once a patient's initial presentation has been determined to be uncomplicated or complicated, the patient's future episodes are likely to follow a similar course.
  • A 1-stage surgical approach with resection and primary anastomosis is often possible in elective settings since the disease is well localized and/or significantly resolved. The bowel must be well vascularized, nonedematous, tension free, and well prepared. The proximal margin should be an area of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third of the rectum where the taenia coalesces. Not all of the diverticula-bearing colon must be removed, since diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.
  • Patients with Hinchey stage I or II disease can usually have preoperative bowel preparation.
• The classic 3-stage surgical approach is now rarely indicated because of high associated morbidity and mortality and is considered only in critical situations in which resection cannot safely be performed.
  • In this approach, the initial operation is simply drainage of the diseased segment and creation of a proximal diversion colostomy, without resection.
  • The second operation is performed 2-8 weeks later to resect the diseased bowel and perform a primary anastomosis.
  • A third operation, performed 2-4 weeks after the second operation, closes the stoma.
• Increasing experience with laparoscopic techniques for colon resection suggests that some of its advantages include less pain, a smaller scar, and shorter recovery time.  There is no change in early or late complications and cost and outcome are comparable to open procedures. This approach is best suited for patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey stage I or II disease.
• Special considerations exist for some forms of complicated diverticulitis. 
  • For diffuse peritonitis, an appropriate initial empiric antibiotic regimen must include either single agent therapy with imipenem/cilastin or piperacillin/tazobactam or multiple drug therapy with ampicillin, gentamicin, and metronidazole. 
  • Obstruction needs to be differentiated from carcinoma, and, even if biopsy results are negative, resection may be necessary to exclude carcinoma if there is enough suspicion based upon appearance alone.
  • Abscesses without peritonitis may be amenable to percutaneous drainage with an elective single-stage operation after the episode has resolved.  Drainage is usually through the anterior abdominal wall but may be done transgluteally or through the rectum or the vagina, depending on the location of the abscess.  Catheter drainage may be helpful in patients who cannot undergo surgery and should be left in place until drainage is less than 10 mL in 24 hours. Catheter sinograms can be performed periodically to monitor the resolution of the abscess cavity before the catheter is removed.
  • Fistulas generally do not close spontaneously, but they may be managed with an elective 1-stage procedure in most cases. Also, in the absence of urinary tract obstruction, observation appears safe in patients with contraindications to surgery.
  • Patients who are immunosuppressed are at an increased risk of perforation, and surgery is necessary in almost all patients who are either already immunosuppressed or are about to start immunosuppressive therapy.

Consultations

• Surgical consultation
• Gastroenterological consultation

Diet

• In mild episodes, a clear liquid diet is advised.  Clinical improvement should occur within 2-3 days, and the diet can then be advanced as tolerated.
• Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis.
• Studies imply a high-fiber diet will prevent progression of diverticulosis.  However, after patients have become symptomatic, the benefit of fiber supplementation is less clear. Recommending to patients to avoid seeds and nuts is currently less common, since it is now thought that seeds and nuts may not play a significant role in the development of diverticulitis, as believed in the past.
• Long-term management probably includes a high-fiber, low-fat diet.

Activity

Normal activity is possible after resolution of the acute episode.

Medication

Diverticulosis is treated with lifelong dietary modification. Antibiotics are used for every stage of diverticulitis. Empiric therapy requires broad-spectrum antibiotics effective against known enteric pathogens. For complicated cases of diverticulitis in hospitalized patients, carbapenems are the most effective empiric therapy because of increasing bacterial resistance to other regimens.

Antibiotics

Empiric antimicrobial therapy is essential and should cover all pathogens likely to cause diverticulitis.

Metronidazole (Flagyl)

Active against various anaerobic bacteria. Enters cell, binds DNA, and inhibits protein synthesis, causing cell death.

Dosing

Adult

Loading: 15 mg/kg IV over 1 h
Maintenance: 7.5 mg/kg PO/IV q6h administered 6 h following loading dose; not to exceed 4 g/d

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with alcohol

Contraindications

Documented hypersensitivity; first trimester of pregnancy

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients with hepatic disease; monitor for seizures and development of peripheral neuropathy; caution in patients with cardiac function impairment, blood dyscrasias, and active organic disease of CNS (eg, epilepsy)

Ciprofloxacin (Cipro)

Bactericidal antibiotic that inhibits bacterial DNA synthesis. Used for infections due to E coli, K pneumoniae, E cloacae, P mirabilis, P vulgaris, P aeruginosa, H influenzae, M catarrhalis, S pneumoniae, S aureus (methicillin susceptible), S epidermidis, S pyogenes, Campylobacter jejuni, Shigella species, and Salmonella typhi.

Dosing

Adult

500 mg PO q12h in combination with metronidazole

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluation of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in patients with renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; may cause arthropathy in children

Amoxicillin/clavulanate (Augmentin)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.
Good alternative antibiotic for patients allergic or intolerant to the macrolide class. Usually is well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. The half-life of oral dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children >3 months, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Dosing

Adult

500-875 mg PO q12h depending on severity of infection
Renal impairment: 875-mg tablet should not be used in patients with CrCl <30 mL/min
CrCl 10-30 mL/min: 250-500 mg PO q12h
CrCl <10 mL/min: 250-500 PO q24h
Hemodialysis: 250-500 PO q24h during and after each hemodialysis session
Hepatic impairment: Monitor hepatic function with prolonged therapy

Pediatric

25-45 mg/kg/d PO divided q12h; depending on severity of infection

Interactions

Coadministration with warfarin or heparin increases risk of bleeding; may act synergistically against selected microorganisms when coadministered with aminoglycosides; coadministration with allopurinol may increase incidence of amoxicillin rash; may decrease efficacy of oral contraceptives when administered concomitantly

Contraindications

Documented hypersensitivity to penicillins or clavulanic acid; history of Augmentin-associated liver dysfunction

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatic impairment may occur with prolonged treatment in the elderly; diarrhea may occur; adjust dose in renal impairment; cross-allergy may occur with other beta-lactams and cephalosporins

Sulfamethoxazole and Trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Dosing

Adult

160 mg TMP/800 mg SMZ PO q12h for 10-14 d
Dosage adjustments (adult adjustments):
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h

Pediatric

<2 months: Do not administer
>2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus); discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding have been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.

Dosing

Adult

Severe infections: 1-2 g IV qd, or divided bid; not to exceed 4 g/d

Pediatric

Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity; hyperbilirubinemic neonates, particularly those who are premature

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; breastfeeding; may displace bilirubin from albumin binding sites increasing the risk of kernicterus; caution with gallbladder, biliary tract, liver, or pancreatic disease; patients with history of colitis or penicillin hypersensitivity

Cefotaxime (Claforan)

Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, which, in turn, inhibits bacterial growth. Used for septicemia and treatment of gynecologic infections caused by susceptible organisms.
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Dosing

Adult

Moderate-to-severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h

Pediatric

Infants and children: 50-180 mg/kg/d IV/IM divided q4-6h
>12 years: Administer as in adults

Interactions

Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; has been associated with severe colitis

Moxifloxacin (Avelox)

Moxifloxacin is the only fluoroquinolone that is FDA approved as monotherapy for the treatment of complicated intra-abdominal infections. Moxifloxacin, a broad-spectrum antibiotic, exhibits activity against Escherichia coli, Bacteroides fragilis, Streptococcus anginosus, Streptococcus constellatus, Enterococcus faecalis, Proteus mirabilis, Clostridium perfringens, Bacteroides thetaiotaomicron, or Peptostreptococcus species. Moxifloxacin is active against gram-positive organisms and anaerobes but less active against Enterobacteriaceae and Pseudomonas species.

Dosing

Adult

400 mg PO q24h; no dosage adjustments for renal and mild-to-moderate liver impairment

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia

Contraindications

Documented hypersensitivity; known Q-T prolongation; concurrent administration of drugs that cause Q-T prolongation

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Potential for QT interval prolongation; avoid use in patients with history of QT interval prolongation, patients with proarrhythmic conditions such as bradycardia or myocardial ischemia, patients on QT-prolonging drugs, and patients with hypokalemia; moxifloxacin may lower the seizure threshold in patients with CNS disorders; fluoroquinolones are associated with tendon rupture, especially in elderly and those on corticosteroids

Levofloxacin (Levaquin)

For pseudomonal infections and infections due to multidrug resistant gram-negative organisms.

Dosing

Adult

500 mg IV qd for 7-14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Ampicillin/Sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Dosing

Adult

3 g (2 g ampicillin and 1 g sulbactam) IV/IM q6h

Pediatric

200 mg/kg/d (ampicillin component) IV/IM divided q6h; maximum 4 g sulbactam/d

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Piperacillin and Tazobactam sodium (Zosyn)

Anti-pseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Dosing

Adult

3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h
Renal impairment:
CrCl >40 mL/min: 3.375 g IV q6h
CrCl 20-40 mL/min: 2.25 g IV q6h
CrCl <20 mL/min: 2.25 g IV q8h
Hemodialysis: 2.25 g IV q12h; 0.75 g supplement after each dialysis session

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication.
Antipseudomonal penicillin and beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative bacteria and most anaerobes.

Dosing

Adult

INF 1 vial containing ticarcillin 3 g IV and clavulanate 0.1 g IV q4-6h over 30 min

Pediatric

75 mg/kg IV q6h

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared with imipenem. Drugs of this class are a good choice for empiric therapy of GI-based infections in hospitalized patients with complicated conditions.

Dosing

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Interactions

Probenecid may inhibit renal excretion of meropenem, thus increasing meropenem levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication

Tigecycline (Tygacil)

Tetracycline type antibiotic with broad coverage, used when the patient has a severe penicillin allergy. FDA approved for complicated intra-abdominal infections.

Dosing

Adult

100 mg IV initially, followed by 50 mg IV q12h
Severe hepatic impairment: 100 mg IV initially, followed by 25 mg IV q12h

Pediatric

Not recommended

Interactions

Coadministration decreases warfarin clearance and increases warfarin C_max and AUC (monitor aPTT and INR); coadministration of antibiotics with oral contraceptives may decrease contraceptive effect

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in severe hepatic impairment (reduce dose); may adversely effect tooth development; may permit clostridia overgrowth, resulting in antibiotic-associated colitis; may have adverse effects similar to tetracyclines (eg, photosensitivity, pseudotumor cerebri, pancreatitis, antianabolic action)

Gentamicin (Gentacidin)

Aminoglycoside antibiotic used to cover gram-negative organisms.
Not the DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM.

Dosing

Adult

Serious infections and normal renal function: 3 mg/kg/d IV q8h
Loading: 1-2.5 mg/kg IV
Maintenance: 1-1.5 mg/kg IV q8h

Pediatric

<5 years: 2.5 mg/kg per dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg per dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non-dialysis dependent renal insufficiency

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Imipenem and cilastatin (Primaxin)

Used for treatment of multiple organism infections as in peritonitis when other agents are not appropriate.

Dosing

Adult

500 mg IV q6h
Adjust dose in renal insufficiency (adult adjustments):
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Interactions

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

Contraindications

Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency; avoid use in children <12 y with CNS infections; caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta-lactam antibiotics

Ampicillin (Principen)

Broad-spectrum penicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Dosing

Adult

2 g IV q4-6h; not to exceed 12 g/d

Pediatric

50 mg/kg IV/IM q4-6h

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Follow-up

Further Inpatient Care

• Emergency colectomy is performed when severe complications arise or when the patient does not respond to medical treatment. Complications requiring surgical intervention include the following: purulent peritonitis, uncontrolled sepsis, fistula, and obstruction. In one retrospective study of over 3000 patients, about 20% of patients admitted for acute diverticulitis required emergency colectomy.
• Elective resection of the involved bowel segment after 2 episodes of uncomplicated diverticulitis to prevent further attacks has been advocated for years. In addition, earlier resection for younger patients with diverticulitis as well as for patients who are immunocompromised has been proposed.  As most complicated diverticulitis occurs on the first presentation and data for elective resection have come from small retrospective studies, this recommendation remains controversial.
• Successful percutaneous drainage of a diverticular abscess has not been associated with greater recurrence or more severe disease and does not necessitate elective colectomy.

Further Outpatient Care

• After recovering from acute diverticulitis, patients should have their colons examined to rule out malignancy. Current modalities include colonoscopy, barium enema, and CT colography (virtual colonoscopy). 
  • Biopsy of suspicious lesions or strictures can be performed during colonoscopy, which is advantageous. 
  • Virtual colonoscopy may be helpful in evaluating diverticulitis in the elective setting. This procedure combines insufflation of the colon in conjunction with a CT scan to provide data that allow computer generation of a 3-dimensional image. At this time, though, the technology is not widely available and does not allow sampling of suspicious lesions.

Deterrence/Prevention

• A lifelong high-fiber diet for those with asymptomatic diverticular disease may reduce the incidence of diverticulitis and its complications.

Complications

• Abscess
• Intestinal fistula
• Intestinal perforation
• Intestinal obstruction
• Peritonitis
• Sepsis and septic shock
• Diverticular bleeding (more common in diverticulosis than diverticulitis)

Prognosis

• Prognosis depends on the severity of illness, the presence of complications, and any coexisting medical problems. Younger patients with diverticulitis may have more severe disease, possibly due to a delay in diagnosis and treatment.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Diverticulosis and Diverticulitis and Abdominal Pain in Adults.

Miscellaneous

Medicolegal Pitfalls

• Failure to realize that the symptoms of diverticulitis may mimic those of multiple conditions is a medicolegal pitfall.
  • Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis.
  • Diverticulitis in the right colon may be confused with acute appendicitis.
• Failure to diagnose colon cancer mimicking diverticular disease leads to a delay in appropriate therapy.

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Keywords

diverticulum, diverticulosis, abdominal pain, chronic diverticular disease, diverticula, inflammation of diverticula, colon, abscess, peritonitis, colovesicular fistula, colovaginal fistula, constipation, colonic motility disorders

Contributor Information and Disclosures

Author

Minh Chau T Nguyen, MD, Assistant Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center; Physician Specialist, Department of Ambulatory Medicine, Olive View-University of California at Los Angeles Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Yuvrajsinh Narendrasinh Chudasama, MD, Staff Physician, Department of Internal Medicine, University of California at Los Angeles, Olive View Medical Center
Yuvrajsinh Narendrasinh Chudasama, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Stanley K Dea, MD, Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology
Stanley K Dea, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy and Southern California Society of Gastroenterology
Disclosure: Nothing to disclose.

Andrea Cooperman, MD, Associate Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center
Andrea Cooperman, MD is a member of the following medical societies: Alpha Omega Alpha and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Waqar A Qureshi, MD, Chief of Endoscopy, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and VA Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

BS Anand, MD, Department of Internal Medicine, Division of Gastroenterology, Professor, Baylor University College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors, Ahmed Sherif, MD, Norvin Perez, MD, and David Greenwald, MD, to the development and writing of this article.

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