A 68-year-old man comes to the emergency department with persistent abdominal pain. Three days ago, the patient received a CT scan of the abdomen and pelvis for abdominal pain and was diagnosed with acute diverticulitis. Since then, he has taken ciprofloxacin and metronidazole, but his symptoms have not improved. The patient has continued nausea, decreased appetite, malaise, and constant left lower quadrant abdominal pain. He has a history of hypertension, hyperlipidemia, and gout. He is a former smoker and occasionally drinks alcohol. Several benign polyps were removed during a colonoscopy 8 years ago. Temperature is 38 C (100.4 F), blood pressure is 140/80 mm Hg, pulse is 102/min, and respirations are 18/min. Abdomen is soft and nondistended, with significant left lower quadrant tenderness but no rebound guarding. Bowel sounds are decreased. Rectal examination reveals left-sided tenderness and negative occult blood stool. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 68-year-old man comes to the emergency department with persistent abdominal pain.  Three days ago, the patient received a CT scan of the abdomen and pelvis for abdominal pain and was diagnosed with acute diverticulitis.  Since then, he has taken ciprofloxacin and metronidazole, but his symptoms have not improved.  The patient has continued nausea, decreased appetite, malaise, and constant left lower quadrant abdominal pain.  He has a history of hypertension, hyperlipidemia, and gout.  He is a former smoker and occasionally drinks alcohol.  Several benign polyps were removed during a colonoscopy 8 years ago.  Temperature is 38 C (100.4 F), blood pressure is 140/80 mm Hg, pulse is 102/min, and respirations are 18/min.  Abdomen is soft and nondistended, with significant left lower quadrant tenderness but no rebound guarding.  Bowel sounds are decreased.  Rectal examination reveals left-sided tenderness and negative occult blood stool.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf2d_2509_8f63_1d19e819fad0_MD0005_00 Patients with diverticulitis who do not symptomatically improve after 2-3 days of treatment should receive repeat CT scan of the abdomen and pelvis to evaluate for complications such as colonic abscess, obstruction, and perforation. Colonic abscess is the most common complication of diverticulitis, occurring in 15%-55% of cases. Symptoms resemble those of diverticulitis and often do not improve with oral antibiotics alone. Diagnosis is usually confirmed by repeat abdominopelvic CT scan, which reveals a localized fluid collection. Most colonic abscesses require percutaneous drainage and intravenous antibiotics followed by elective partial colectomy several weeks later. (Choice A) Emergency laparotomy and colectomy are often required if diverticulitis leads to perforation. However, a CT scan of the abdomen and pelvis is usually required for diagnosis prior to an operation. (Choice C) Colonoscopy should be performed in most patients with diverticulitis 6-8 weeks after the complete resolution of symptoms to rule out colon cancer. Colonoscopy would not be prudent at this time due to a risk for perforation. (Choice D) This patient with no improvement of symptoms after 3 days of therapy has effectively "failed" outpatient treatment with oral antibiotics. Continuing antibiotics puts him at risk for worse infection with potentially life-threatening complications (eg, perforation). He requires another abdominopelvic CT scan. (Choice E) Although intravenous antibiotics, a clear liquid diet, and hospitalization are likely indicated, observation for 24-48 hours without abdominal imaging would be unwise as diverticulitis complications (eg, abscess, perforation) often require urgent percutaneous or surgical treatment. Educational objective: When diverticulitis does not improve after 2-3 days of antibiotic therapy, repeat abdominopelvic CT scan is required to evaluate for complications (eg, abscess, perforation, obstruction). Colonoscopy is contraindicated in patients with acute diverticulitis. References: Diagnostic imaging for diverticulitis. (http://www.ncbi.nlm.nih.gov/pubmed/18936653)

A 68-Year-Old Man Comes to the Emergency Department with Persistent