A 61-year-old man comes to the emergency department with abdominal pain for the past 2 days. He has lower abdominal discomfort and generalized malaise but no nausea, vomiting, back pain, or urinary symptoms. His last bowel movement was yesterday. The stool was formed but did not relieve the pain. He has never had a colonoscopy. His father was diagnosed with colon cancer at age 65.
His temperature is 37.8 C (100 F), blood pressure is 122/70 mm Hg, and pulse is 92/min. Mucous membranes are moist. There is moderate tenderness in the left lower quadrant without rebound tenderness.
Laboratory results are as follows:

Computed tomography of the abdomen with contrast shows sigmoid wall thickening and increased density of the pericolic fat.
Which of the following is the best management for this patient?

Question

A 61-year-old man comes to the emergency department with abdominal pain for the past 2 days.  He has lower abdominal discomfort and generalized malaise but no nausea, vomiting, back pain, or urinary symptoms.  His last bowel movement was yesterday.  The stool was formed but did not relieve the pain.  He has never had a colonoscopy.  His father was diagnosed with colon cancer at age 65.
His temperature is 37.8 C (100 F), blood pressure is 122/70 mm Hg, and pulse is 92/min.  Mucous membranes are moist.  There is moderate tenderness in the left lower quadrant without rebound tenderness.
Laboratory results are as follows:

Computed tomography of the abdomen with contrast shows sigmoid wall thickening and increased density of the pericolic fat.
Which of the following is the best management for this patient?

Quizplus · Accepted Answer

11ec193a_9810_37f3_853d_25e6eb17e9a2_MD0002_00 This patient's presentation is consistent with acute uncomplicated diverticulitis. Uncomplicated diverticulitis accounts for 75% of all cases and presents with left lower-quadrant pain/tenderness, fever, and leukocytosis. Computed tomography (CT) scan usually shows soft-tissue stranding and colonic wall thickening. Uncomplicated diverticulitis can be managed with outpatient oral antibiotics for 7-10 days, bowel rest with gradual transition to fluid intake, and close follow-up. Hospitalization with intravenous broad-spectrum antibiotics is indicated for patients with high fever or significant leukocytosis, immunosuppression, inability to tolerate oral intake, or significant comorbidities. Complicated diverticulitis is associated with an abscess, perforation, obstruction, or fistula formation. Intravenous antibiotic therapy is preferred in these patients. CT-guided drainage is indicated for abscesses > 3 cm. Surgery is considered for patients with worsening clinical course despite adequate therapy or abscesses not responding to catheter drainage (Choice A). (Choices B, C, and E) This patient is clinically stable without significant comorbidities. He has good oral intake and can be treated with oral antibiotics without hospitalization. Sigmoidoscopy or colonoscopy should be done 2-6 weeks after recovery to exclude underlying malignancy. A repeat CT scan would be indicated only if conditions worsen. Educational objective: Uncomplicated diverticulitis can be managed with outpatient oral antibiotics, bowel rest with gradual transition to fluid intake, and close follow-up. Hospitalization is indicated for patients with high fever or significant leukocytosis, poor oral intake, significant comorbidities, or immunosuppression. Complicated diverticulitis usually requires intravenous antibiotics and possible computed tomography-guided drainage of fluid collections. __________ References: Features and management of colonic diverticular disease. (http://www.ncbi.nlm.nih.gov/pubmed/20694839) Current management of diverticulitis. (http://www.ncbi.nlm.nih.gov/pubmed/19062658)

A 61-Year-Old Man Comes to the Emergency Department with Abdominal