Diagnosing Diverticulitis Properly
Appropriate medical treatment for diverticulitis includes relieving pain, providing IV fluids, prohibiting oral intake of anything other than occasional clear fluids, and starting aggressive therapy with broad-spectrum antibiotics. A similar regimen is recommended for patients not sick enough to be hospitalized.
Resting the bowel is essential. As tenderness subsides and the WBC count goes down, the diet can gradually advance from liquids to soft foods. After the patient has improved sufficiently, appropriate diagnostic procedures, such as barium enema, may be cautiously administered. Only then can a balanced, high-fiber diet be safely resumed or instituted. In the past, it was thought to be appropriate to begin a high-fiber diet as soon as the patient could take solid foods; this is now considered contraindicated for the patient recuperating from acute diverticulitis.
Analgesics less potent than meperidine HC1 (Demerol) are recommended for relief of pain whenever possible. If meperidine is necessary, the recommended dosage is 50-100 mg IM q3-4h, for as short a time as possible. Ideally, the patient should soon be able to get by on aspirin or acetaminophen, especially at home.
Morphine sulfate is not an acceptable substitute for meperidine because it tends to increase pressure in the already highly stressed colon. The circular muscle, often somewhat thickened by diverticulosis, would be further thickened by morphine and might close off a segment of the colon. In turn, the resultant increased pressure might cause ballooning and penetration of the diverticula in the closed-off region. Antibiotic therapy is a matter of wide choice with one or more of the broad-spectrum agents known to be effective against the expected colonic flora. The usual recommended agents include: * Cefoxitin sodium (Mefoxin), 2 g IV q6-8h, for a maximum of 6-8 g/d. This agent may be given alone or concurrently with one or both of the next two agents. * Gentamicin sulfate (Garamycin), 1 mg/kg IM q8h, for a maximum of 3 mg/kg/d. NOTE: This potentially nephrotoxic drug should not be given with potent diuretics or other nephrotoxic drugs and should be used concurrently with other antibiotics. * Metronidazole (Flagy I.V.), a loading dose of 15 mg/kg infused over one hour, followed after six hours by 7.5 mg/kg q6h infused over one hour. NOTE: This drug is to be administered by slow IV drip infusion only. It should be used concurrently with other antibiotics. * Sterile mezlocillin sodium (Mezlin), 200-300 mg/kg/d IV in 4-6 divided doses. The usual dosages are 3 g q4h or 4 g q6h. For life-threatening infections, up to 350 mg/kg/d may be given; with a maximum of 24 g/d. Mezlocillin may be given concurrently with metronidazole or other agents. In life-threatening sepsis, clindamycin phosphate (Cleocin) or dicyclomine HC1 (Bentyl) may be an option, but administration and dosage of either drug must be determined for each patient on an individualized risk-benefit basis. Problems that mimic Diverticulitis Causes are so numerous that ruling out even the most likely ones is next to impossible without roentgenography and colonoscopy. During an acute attack, doing the appropriate diagnostic procedures may be both difficult and dangerous. Unless surgical necessity demands immediate, accurate information, postponing diagnostic testing other than plain X-ray films may be the wisest decision.
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