Review Question - QID 103338

An elderly patient with left lower quadrant pain in the setting of poor fiber intake and similar prior admissions is most likely to be suffering from diverticulitis. In this case, abdominal guarding and rebounding along with CT evidence of perforation suggest it to be perforated diverticulitis, which should be treated operatively.

Diverticulitis is one of the most common causes of left lower quadrant pain in elderly patients. It increases in incidence with age and decreased fiber intake and is more common among Caucasian patients. Overgrowth of bacteria in the mucosal outpouchings of the sigmoid colon can cause inflammation, converting diverticulosis to diverticulitis, which can typically be treated with a course of antibiotics. Diverticulitis can be complicated by abscess, fistula, obstruction, bleeding, or perforation requiring additional, often operative, treatment.

Wilkins et al. discuss the management of diverticulitis in the general population. They state that isolated left lower quadrant tenderness in elderly patients has a 10 fold increased likelihood of being caused by diverticulitis. Furthermore, they state that though uncomplicated diverticulitis can be treated on an outpatient basis, if the patient cannot tolerate PO intake or has any signs of peritonitis, the patient should be admitted for further testing.

Khalil et al. discuss the management of perforated diverticulitis in patients. They state feculent peritonitis caused by perforated diverticulitis has a mortality rate ranging from 14% to 43%. Perforation should be treated emergently with a bowel resection and an end-to-end anastomosis or resection with a reversible stoma.

Figure A shows an axial CT slice with a perforation in the sigmoid colon, likely in the setting of diverticulitis. Illustration A is a good example of complicated diverticulitis presenting with abscess formation.

Incorrect Answers:

Answer 1 and 5: Though this patient should receive antibiotics, surveillance and fluids alone are not the next best options for this patients since he has a perforated abdomen that can result in multiple, potentially lethal complications such as abscess formation, sepsis, and shock.
Answer 2: The patient should not be discharged home because he is clearly sick and requires operative treatment.
Answer 4: Percutaneous drainage may be appropriate if this patient presented with an accessible abscess, but this patient does not present with a drainable collection.