Diverticulitis: Clinical sciences

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A 63-year-old man presents to the emergency department with a three-day history of worsening lower abdominal pain, nausea, and fever reaching 38.9°C (102.0°F). The patient has had two episodes of diverticulitis in the past two years, which were treated with oral antibiotics. Past medical history is significant for diabetes mellitus. Temperature is 39.0 °C (102.2°F), blood pressure is 112/68 mmHg, pulse is 96/min, and respirations are 20/min. There is localized tenderness to palpation over the left lower quadrant. Serum white blood cell count is elevated. CT scan of the abdomen and pelvis with IV and oral contrast shows a 2.2-centimeter abscess around the sigmoid colon and multiple colonic inflamed diverticula with localized bowel wall thickening and pericolonic fat stranding. Which of the following is the most appropriate next step in management?  

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Diverticulitis is inflammation of a diverticulum, which is a small pouch protruding from the bowel wall. Be sure not to mix it up with diverticulosis, which is the presence of multiple diverticula that develop because of a high-fat and low-fiber diet. However, even though it is commonly believed, eating things like seeds, nuts, and popcorn does not increase the risk of developing diverticulosis or diverticulitis.

Now, diverticulitis occurs when increased bowel pressure, from things like food or stool, causes a tiny hole or micro perforation in the diverticulum wall. This allows bacteria from the lumen to seed the diverticulum, which results in infection and inflammation. Diverticulitis can be classified as uncomplicated or complicated diverticulitis. In uncomplicated diverticulitis, only the diverticulum is inflamed, while in complicated diverticulitis, perforation, abscess, or fistula might be present as well.

Alright, when a patient presents with signs and symptoms of diverticulitis, you should first perform an ABCDE assessment. The individual can be  unstable if septic shock develops, so you should stabilize their airway, breathing, and circulation. This means that you may need to intubate the patient, establish IV access, or administer fluids before continuing with your assessment.

However, if the patient is stable, the next step is to obtain a focused history and physical examination. History typically reveals abdominal pain, most often in the left lower quadrant, and sometimes symptoms like fever, nausea, vomiting, and recent changes in bowel habits, such as constipation or diarrhea.

Physical examination usually reveals abdominal distention and tenderness in the affected area, most commonly in the left lower quadrant. There can also be elevated temperature. The most dangerous signs to look for are guarding, rigidity, and rebound pain, which point to peritonitis.

A rectal examination may reveal a palpable mass within the distal sigmoid colon. The stool may also be positive for occult blood.

Sources

  1. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis" Diseases of the Colon & Rectum (2020)
  2. "EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice" Surgical Endoscopy (2019)
  3. "American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis" Gastroenterology (2015)
  4. "Colon, Rectum, and Anus. " Schwartz’s Principles of Surgery McGraw-Hill Education (2014)
  5. "Epidemiology, Pathophysiology, and Treatment of Diverticulitis" Gastroenterology (2019)
  6. "Diverticulitis in the United States: 1998–2005" Annals of Surgery (2009)