eMedicine Specialties > Gastroenterology > Intestine

Diverticulosis, Small Intestinal: Treatment & Medication

Author: Lisa Ozick, MD, Chief, Division of Gastroenterology, Harlem Hospital Center
Coauthor(s): Rohan C Clarke, MD, Attending Gastroenterologist, JPS Health Systems Hospital, Fort Worth, Texas; Oluyinka S Adediji, MD, Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama
Contributor Information and Disclosures

Updated: Apr 12, 2006

Treatment

Medical Care

The general recommendation favors a conservative approach to the management of asymptomatic diverticula. They are generally left alone unless they can be related to diseases. In certain locations, diverticula are associated with special complications. For example, periampullary diverticula can be associated with pancreatitis, cholangitis, or recurrent choledocholithiasis after cholecystectomy. Intraluminal diverticula are observed in the duodenum. They can be complicated by intestinal obstruction and biliary and pancreatic diseases. A higher complication rate is associated with jejunoileal diverticulosis and, as such, may justify less conservative approach to its management. Capsule endoscopy might be of value if available to identify the site of the bleed. Push enteroscopy should be used once a lesion amenable to therapeutic intervention has been identified.

• Prehospital care: Acute abdomen and obvious and occult GI hemorrhage are the clinical scenarios that necessitate prehospital intervention. Vascular access, intravenous fluid, oxygen, and prompt transport to the hospital are all that is required in the field.
• Medical management
  • Abdominal pain without clinical evidence of diverticulitis or intestinal obstruction requires no specific treatment. Patients benefit from the use of bulk-forming agents, such as fiber, bran, and cellulose products. Intractable pain associated with anemia and jejunal loop dilatation on radiograph should heighten concern for jejunal diverticulosis.
  • For diverticulitis, patients often require hospitalization because preoperative diagnosis of small bowel diverticulitis is difficult. Initial interventions include the following:
    • Bed rest
    • Nothing by mouth and/or nasogastric suctioning
    • IV fluid
    • Broad-spectrum antibiotic coverage
    • Surgical consultation: Urgent surgery rarely is indicated unless perforation, abscess, or neoplasm is suspected.
• Management of complications: The approach to management of complicated small bowel diverticula involves initiation of medical and supportive management. Surgical consultation must be performed promptly. Patients can present with the following complications:
  • GI bleeding and/or hemorrhage
    • Patient is treated with IV fluid and blood products as necessary.
    • Diagnostic workup is usually completed in the intensive care setting.
    • Most patients stop bleeding, allowing elective surgery.
    • Mesenteric angiography with infusion of vasoconstrictors can be used in persistent hemorrhage.
    • Laparotomy may be indicated as an emergency therapy for continuing bleeding or as elective treatment if bleeding responds to conservative management.
  • Intestinal perforation: Early surgery is the treatment of choice. Fluid and electrolyte management as well as antibiotics are essential adjuncts.
  • Intestinal obstruction: Initial management is similar to uncomplicated diverticulitis. Urgent surgical consultation is mandatory.
  • Intestinal pseudoobstruction: Cautious conservative management is indicated while excluding mechanical obstruction.
  • Fistula formation: This is a rare complication.
  • Malabsorption: This is often a complication of bacterial overgrowth resulting from blind loop syndrome. It usually responds to antibiotics.
  • Preoperative diagnosis of diverticula is seldom made. This can present as intussusception, volvulus, or pseudoobstruction.

Surgical Care

• Complications of small bowel diverticulosis, such as massive bleeding or diverticulitis with perforation, require surgery. Diagnosis is seldom made preoperatively. The aim is to control complications when present and/or to prevent future complications.
• Emergency surgery is indicated for severe diverticulitis, intestinal perforation, intestinal obstruction, and hemorrhage that continue after conservative management.
• Several operative procedures are available depending on the type of diverticulum, site, and nature of complications.
• Simple diverticulectomy
  • This is most commonly used for symptomatic diverticulum or bleeding diverticulum of the duodenum. The diverticulum is simply excised, and the bowel is closed longitudinally or transversely, ensuring minimal luminal stenosis.
  • This procedure requires modification in cases involving a diverticulum that is embedded deep in the head of the pancreas or is associated with the ampulla of Vater, is perforated, or is intraluminal in location. It can be technically difficult in the presence of common duct obstruction. These patients benefit more from choledochoduodenostomy.
  • Meckel diverticulum can also be removed by this technique.
• Intestinal resection and end-to-end anastomosis: This is the preferred approach to jejunoileal diverticulum, which tends to be multiple, irrespective of types of complications.
• Enterotomy: This can be performed solely to remove enterolith of diverticular origin causing distal obstruction.
• Caveats of surgical management: Perforated duodenal diverticulum requires a special approach. Simple excision and closure may be complicated by obstruction; therefore, consider complete diversion of the bowel from the duodenum, then perform vagotomy, antrectomy, closure of the duodenal loop, and Billroth II anastomosis. Dysmotility alone without obstruction is not an indication for bowel resection because resection would not prevent propagation of motility disorder.

Consultations

• Consultation with a general surgeon is indicated for all patients requiring surgical management.
• A gastroenterologist assists with diagnosis and follow-up strategy and performs both diagnostic and therapeutic endoscopy.

Diet

The role of diet is not clear. A high-fiber diet that improves bowel motility and is used in colonic diverticulosis may be beneficial.

Activity

No restriction of activity is indicated.

Medication

Antibiotics are important in the management of diverticulitis and related complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Antibiotic combinations are usually recommended for serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections. In addition, it prevents resistance from bacterial subpopulations and provides additive or synergistic effects. Once organisms and sensitivities are known, the use of antibiotic monotherapy is then recommended. Antibiotics can be administered PO in mild disease and unambiguous diagnosis, otherwise administer IV.

Metronidazole (Flagyl)

Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate metabolized compounds that are formed, binding DNA and inhibiting protein synthesis, which causes cell death.

Clindamycin (Cleocin)

Effective against aerobic and anaerobic streptococci but not enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)

Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms.

Amoxicillin (Trimox, Amoxil, Biomox)

Can be used PO when outpatient treatment is indicated. Interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in a bactericidal activity against susceptible bacteria.

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Imipenem and cilastin (Primaxin)

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

Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

Ticarcillin and clavulanate potassium (Timentin)

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

Ampicillin and sulbactam sodium (Unasyn)

Drug combination antimicrobial agents consisting of a beta-lactamase inhibitor and ampicillin. Active against skin, enteric flora, and anaerobes.

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