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Diverticulitis Workup

  • Author: Kamyar Shahedi, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Jun 17, 2016
 

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 colovesical 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.

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Imaging Studies

The diagnosis of diverticulitis can be made on clinical grounds, but a computed tomography (CT) scan of the abdomen is considered the best imaging method to confirm the diagnosis. The American College of Radiology (ACR) 2008 Appropriateness Criteria for left lower quadrant pain support this recommendation because of the specificity and sensitivity of CT scans, which allow for the diagnosis of causes of left lower quadrant pain that resembles diverticulitis.[10]  Note the following:

  • 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 scan 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. According to the 2008 ACR Appropriateness Criteria, contrast enema may be an option when CT scans do not absolutely differentiate between diverticulitis and colonic carcinoma.[10]

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.

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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.

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Staging

Several staging schemes have been proposed based on the 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 - Phlegmon or localized pericolic or mesenteric abscess
  • Stage II disease - Walled-off pelvic, intra-abdominal, or retroperitoneal abscess
  • 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
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Contributor Information and Disclosures
Author

Kamyar Shahedi, MD Clinical Instructor, Olive View-UCLA Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Kamyar Shahedi, MD is a member of the following medical societies: American College of Physicians, American Medical Association, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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, Southern California Society of Gastroenterology

Disclosure: Nothing to disclose.

Yuvrajsinh Narendrasinh Chudasama, MD Staff Physician, Department of Internal Medicine, Olive View-UCLA Medical Center; Assistant Clinical Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine

Yuvrajsinh Narendrasinh Chudasama, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Duminda B Suraweera, MD Resident Physician, Department of Medicine, Olive View–UCLA Medical Center

Duminda B Suraweera, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor 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, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor 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.

David Greenwald, MD Associate Professor of Clinical Medicine, Fellowship Program Director, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Norvin Perez, MD Medical Director, Juneau Urgent and Family Care

Norvin Perez, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Waqar A Qureshi, MD Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs 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.

Ahmed Sherif, MD Staff Physician, Department of Internal Medicine, Montefiore Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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