Review Question - QID 106561

This woman with a history of diverticulosis presents with signs and symptoms of acute diverticulitis. She should receive a CT scan to further workup the diagnosis.

Twenty to twenty-five percent of individuals with diverticulosis will develop diverticulitis in their lifetime. Typical symptoms include left lower quadrant abdominal pain, nausea, dysuria, and diarrhea or constipation. Patients may present with peritonitis if there is an intraabdominal abscess. For a first episode of mild diverticulitis, treatment includes bowel rest, low roughage diet, and followup in 2-3 days. Despite evidence showing a lack of efficacy of broad spectrum antibiotics, most patients managed as outpatients are still prescribed broad spectrum antibiotics with regimens such as trimethoprim-sulfamethoxazole or fluoroquinolones + metronidazole. Prior to treatment, CT imaging is often performed, in particular, in older patients.

Wilkins et al. discuss the diagnosis and management of acute diverticulitis. They conclude that antibiotic therapy does not accelerate recovery or prevent complications or recurrence of diverticulitis. For patients with peritonitis or concern for complications such as abscess or fistula formation, inpatient management and imaging (CT with PO and IV contrast) is warranted. Additionally, as many as 30% of individuals hospitalized for diverticulitis will require surgical intervention, with laparoscopic surgery being associated with shortened length of hospital stay.

Shabanzadeh et al. discuss the role of antibiotic therapy for uncomplicated diverticulitis. In their meta-analysis they found that there was no statistically significant difference between management with and without antibiotics. They conclude that as more studies elucidate the impact or lack thereof of antibiotic therapy in uncomplicated diverticulitis, clinical guidelines will have to be adjusted to fit the most up to date science.

Figure A shows endoscopic view of the sigmoid colon with multiple diverticula in view, diagnostic for diverticulosis.

Incorrect Answers:
Answer 1: Immediate colonoscopy would not be appropriate due to the risk of rupture or complications. Follow up colonoscopy in 4-6 weeks after resolution is appropriate in complicated diverticulitis.
Answer 2: Empiric treatment with antibiotics may be appropriate if imaging is not available. However, the high mortality associated with abdominal pain in older patients would warrant CT imaging prior to treatment.
Answer 4: CT angiography is the diagnostic tool of choice for mesenteric ischemia, not diverticulitis.
Answer 5: Laparotomy and surgical management is reserved for patients with evidence of perforation or ischemia. Sigmoid colectomy for diverticulitis is the treatment of choice for complicated or recurrent diverticulitis after resolution of the acute episode.