A 63-year-old man comes to the physician for routine follow-up after an episode of acute diverticulitis. Four weeks ago, he was admitted to the hospital with severe abdominal pain and vomiting. Computed tomography scan of the abdomen at that time showed sigmoid wall thickening and increased density of the pericolic fat. He was treated with intravenous fluids and antibiotics before completing oral antibiotics as an outpatient.
The patient has no abdominal pain and a good appetite. He suffers from chronic constipation and takes fiber supplements. A colonoscopy 6 years ago was normal. His father was diagnosed with colon cancer at age 65.
His temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 70/min. There is minimal tenderness in the left lower quadrant on deep palpation.
Which of the following is the best next step in managing this patient?

Question

A 63-year-old man comes to the physician for routine follow-up after an episode of acute diverticulitis.  Four weeks ago, he was admitted to the hospital with severe abdominal pain and vomiting.  Computed tomography scan of the abdomen at that time showed sigmoid wall thickening and increased density of the pericolic fat.  He was treated with intravenous fluids and antibiotics before completing oral antibiotics as an outpatient.
The patient has no abdominal pain and a good appetite.  He suffers from chronic constipation and takes fiber supplements.  A colonoscopy 6 years ago was normal.  His father was diagnosed with colon cancer at age 65.
His temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 70/min.  There is minimal tenderness in the left lower quadrant on deep palpation.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Atypical colon cancer (local invasion, contained perforation) can present similarly to acute diverticulitis. Imaging studies during the acute episode may not detect underlying neoplasia. Diverticulitis can recur in up to 1/3 of cases, and diverticulosis may lead to potential bleeding. As a result, colonoscopy is recommended after the acute diverticulitis episode to evaluate for underlying malignancy and assess the severity of the diverticulosis. The test should ideally be done 2-6 weeks after recovery. Flexible sigmoidoscopy plus barium enema is an alternate test for patients unable to tolerate colonoscopy. (Choice B) Although repeat imaging may show resolution of diverticulitis, it would not be as sensitive as colonoscopy in ruling out underlying malignancy. (Choice C) Patients had previously been advised to avoid whole-fiber foods (eg, seeds, corn, and nuts) as undigested fragments may get stuck in a diverticulum and cause diverticulitis. However, the Health Professionals Follow-up Study (a large observational study) found an inverse association between consumption of nuts/popcorn and the risk of diverticulitis and diverticular bleeding. (Choice D) Patients should initially be instructed to consume only clear liquids and gradually advance to a high-fiber diet. Several guidelines suggest a high-fiber diet to possibly reduce recurrence of diverticulitis. For this patient, high-volume fluid intake would not change the risk of recurrence, but a high-fiber diet may help reduce recurrences. (Choice E) Surgery is usually indicated for complicated (eg, peritonitis, perforation, abscess, fistula, or obstruction) or recurrent diverticulitis. Educational objective: Colonoscopy is indicated after an episode of diverticulitis to rule out malignancy and assess the severity of disease. Recommendations to decrease consumption of nuts and seeds have not altered outcomes. A high- fiber diet may reduce diverticulitis recurrence. __________ References: Current management of diverticulitis. (http://www.ncbi.nlm.nih.gov/pubmed/19062658) Features and management of colonic diverticular disease. (http://www.ncbi.nlm.nih.gov/pubmed/20694839) Lifestyle factors and the course of diverticular disease. (http://www.ncbi.nlm.nih.gov/pubmed/22572683)

A 63-Year-Old Man Comes to the Physician for Routine Follow-Up