A 60-Year-Old Man With Intense Left-Sided Abdominal Pain

Pramod Gupta, MD; Jitendra Gohil, MD

Disclosures

October 12, 2016

The management of patients with acute diverticulitis depends on the severity of the illness, but medical management alone is commonly successful. Well-appearing patients who are able to tolerate oral intake and do not have systemic symptoms, peritonitis, or complications seen on CT may be treated as outpatients.

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Some nontoxic-appearing patients with a history of diverticulitis who present with their typical symptoms may be treated empirically as outpatients, without repeat imaging, if no significant comorbidities (eg, an immunocompromised state, diabetes, or cancer) are noted. All patients treated at home require close follow-up care and reexamination, and they should be given detailed return precautions for worsening pain or systemic illness.

Treatment of uncomplicated acute diverticulitis consists of bowel rest, broad-spectrum antibiotics, and pain control. Outpatients may be instructed to begin with a clear liquid diet and advance slowly as tolerated, whereas inpatients should be kept hydrated with intravenous fluids. Antibiotic regimens should cover gram-negative bacteria and anaerobes. A combination of either trimethoprim/sulfamethoxazole or ciprofloxacin, with either metronidazole or clindamycin, is the primary recommended treatment regimen. Monotherapy with amoxicillin/clavulanic acid is an acceptable alternative regimen.[1,2]

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Patients should be admitted to the hospital if they cannot tolerate oral intake of fluids, are immunocompromised, demonstrate signs of systemic toxicity (such as tachycardia and fever), or have developed evidence of peritonitis or intra-abdominal complications. These patients should receive nothing by mouth and be given intravenous antibiotics. Ciprofloxacin or an aminoglycoside may be paired with metronidazole or clindamycin as the recommended antibiotic regimen. A monotherapeutic agent, such as piperacillin/tazobactam, ampicillin/sulbactam, or ertapenem, may also be used.[1]

Selected abscesses detected by ultrasonography or abdominal CT may be drained percutaneously, whereas perforations, fecal peritonitis, and fistula formation all require surgical consultation. Abscesses less than 5 cm in diameter can be treated with antibiotics alone, although evaluation by a surgeon should still be sought. Recurrent diverticulitis and complicated diverticulitis are indications for partial colonic resection.

Approximately 10%-25% of patients who are medically managed have recurrent attacks and are at an increased risk for subsequent complications. Of note, patients younger than 40 years are more likely to have recurrences and are more likely to benefit from elective sigmoid resection.[1,2]

In this case, the axial CT images of the abdomen at the level of the pelvis (Figures 2 and 3) show acute diverticulitis of the sigmoid colon. Multiple diverticula (arrowheads) and wall thickening are noted (Figure 4), and inflammatory stranding is seen in the sigmoid mesentery (Figure 5). No free air or abscess formation is evident. The screening barium enema performed 3 years ago (Figure 6) shows multiple diverticula in the sigmoid and descending colon (arrowheads).

Because of systemic signs and symptoms of infection, this patient was admitted to the hospital. He was placed on bowel rest and started on intravenous metronidazole and ciprofloxacin. Over the next 2 days, the patient defervesced and his leukocytosis resolved. His diet was advanced to a full diet, and he was discharged from the hospital on a 10-day course of amoxicillin/clavulanic acid.

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