Diverticulitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2],Seyedmahdi Pahlavani, M.D. [3], Omodamola Aje B.Sc, M.D. [4], Ahmed Elsaiey, MBBCH [5]

Overview

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis. Diverticulitis must be also differentiated from diseases causing peritonitis.

Differentiating Diverticulitis from other Diseases

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever. Diverticulitis must be also differentiated from diseases causing peritonitis.

Differentiating diverticulitis from diseases causing lower abdominal pain and fever

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis.

Diseases		Symptoms		Signs			Diagnosis		Other Features
		Location of abdominal pain	Bowel habits	Rebound tenderness	Guarding	Genitourinary signs	Lab findings	Imaging
GI diseases	Diverticulitis	Left lower quadrant (LLQ)	Constipation or Diarrhea	-	+	+	Leukocytosis	CT scan show evidence of inflammation
	Appendicitis	LLQ / RRQ	Constipation	+	+	-	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea and vomiting, decreased appetite
	Inflammatory bowel disease	LLQ	Bloody diarrhea	-	-	-	Leukocytosis		Colonoscopy and tissue sampling are recommended for differentiating between Crohn's disease and ulcerative colitis
	Colon carcinoma	LLQ	Constipation	-	-	-	Serum carcino-embryogenic antigen  Low serum vitamin B12 Hypercalcemia	CT scan, X-ray and MRI show metastasis
	Strangulated hernia	LLQ	-	-	-	-	No specific tests	CT scan used to detect the hernia and to show if it is single or multiple
Gentiourinary diseases	Cystitis	LLQ	-	+	-	Supra-pubic tenderness	Pyuria Presence of nitrites and leukocyte estrase	X-ray is done to rule out the suspicion of emphysematous cystitis CT scan shows gas in the bladder in cases of emphysematous cystitis
	Prostatitis	LLQ Groin pain	-	-	-	Tender and enlarged	Serum PSA elevated Leukocytosis Elevated CRP	CT scan shows edema and enlarged prostate Abscess may be observed
	Pelvic inflammatory disease	Bilateral	-	-	-	Purulent vaginal discharge	Nucleic acid amplification tests is the best laboratory test for PID	Transvaginal utrasonography
Gynecological diseases	Endometritis	LLQ	-	+	-	+	No specific tests	Ultrasound is helpful to rule out other differential diagnosis such as pelvic abscess, thrombosis and masses	Vaginal discharge Vaginal bleeding
	Salpingitis	LLQ/ RLQ		+/-	+/-		Leukocytosis	Pelvic ultrasound	Vaginal discharge

Differentiating diverticulitis from diseases causing peritonitis

The following table differentiates diverticulitis from other diseases causing peritonitis:

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid shows polymorphonuclear cells (PMN) >250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright chest x- ray (CXR) Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + intravenous (IV) antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic symptoms Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable bowel syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber Osmotic laxatives Antispasmodicdrugs Differentiating diverticulitis from diseases causing chronic diarrhea The following diseases must be differentiated from diverticulitis presenting with chronic diarrhea. Cause History Laboratory findings Diagnosis Treatment Diverticulitis Bloody diarrhea Left lower quadrant abdominal pain Abdominal tenderness on physical examination Low grade fever Leukocytosis Elevated serum amylase and lipase Sterile pyuria on urinalysis Abdominal CT scan with oral and intravenous (IV) contrast Bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods A 7-10 day course of oral, broad-spectrum antibiotic therapy is the first line of therapy for acute uncomplicated diverticulitis. Hospital admission is indicated for elderly patients and patients with multiple comorbidities, compromised immune systems, inability to tolerate oral hydration, or failure to improve despite appropriate antibiotic therapy. Hospitalized patients often require bowel rest, nasogastric tube placement, and parenteral antibiotics. Outpatients should be advised to follow a liquid diet for 2-3 days, after which a regular diet may be resumed slowly. Ulcerative colitis Diarrhea mixed with blood and mucus, of gradual onset. Signs of weight loss Rectal urgency Tenesmus Blood is often noticed on underwear Different degrees of abdominal pain Anemia Thrombocytosis A high platelet count Elevated ESR (>30mm/hr) Low albumin Endoscopy Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease. Amoebiasis Abdominal cramps Diarrhea Passage of 3 - 8 semiformed stools per day Passage of soft stools with mucus and occasional blood Fatigue Intestinal gas (excessive flatus) Rectal pain while having a bowel movement (tenesmus) Unintentional weight loss Cysts shed with the stool Detects amoeba DNA in feces Amebic dysentery Metronidazole 500-750mg three times a day for 5-10 days Tinidazole 2g once a day for 3 days is an alternative to metronidazole Luminal amebicides for E. histolytica in the colon: Paromomycin 500mg three times a day for 10 days Diloxanide furoate 500mg three times a day for 10 days Iodoquinol 650mg three times a day for 20 days For amebic liver abscess: Metronidazole 400mg three times a day for 10 days Tinidazole 2g once a day for 6 days is an alternative to metronidazole Diloxanide furoate 500mg three times a day for 10 days must always be given afterwards. References