Your patient returns to clinic for his scheduled follow up appointment 7 days later. His abdominal pain and diarrhea have resolved.
What further testing do you recommend for this patient?
The patient feels better. No further follow up necessary.
Incorrect. Try again!
Repeat CT Abdomen/Pelvis in 4 weeks
Incorrect. Repeat imaging is only recommended if patients fail to improve on antibiotics.
Colonoscopy in 6-8 weeks.
Correct! AGA guidelines recommend that patients undergo outpatient colonoscopy 6-8 weeks after symptom resolution to exclude the presence of colonic neoplasm.
The patient is also curious about lifestyle and/or medications to prevent disease recurrence.
What do you recommend? (more than 1 may apply!)
Weight loss.
Correct! Obesity is associated with increased risk of diverticulitis. Weight loss and maintaining a normal BMI should be encouraged.
Probiotics
Incorrect. There’s insufficient evidence to suggest benefit with probiotic use. Try again!
Smoking Cessation
Correct! Smoking is a risk factor for diverticulitis. Cessation should be encouraged.
High quality/high-fiber diet
Correct! Dietary intake of foods high in fiber (fruits, vegetables, whole grains, and legumes) and low in red meats and sweets are associated with decreased risk of diverticulitis.
Vigorous physical activity
Correct! AGA guidelines provide this recommendation based on a modest decreased incidence seen in observational studies.
Mesalamine treatment
Incorrect. Randomized controlled studies have shown no benefit to mesalamine compared to placebo in preventing diverticulitis recurrence.
Avoid NSAIDs
Correct! NSAIDs are associated with increased risk of diverticulitis and should be avoided.
Avoid aspirin
Incorrect. While observational data shows a slight increase in risk of diverticulitis with aspirin use, the established benefit of aspirin in secondary prevention of CAD outweighs any risk of recurrent diverticular disease.
3 Years Later….
Your patient returns to the emergency room with recurrent left lower quadrant abdominal pain and diarrhea associated with generalized malaise, fevers, and chills. He says his current symptoms feel similar to his prior episode of diverticulitis, though now more severe. He has not tolerated oral intake for the past 2 days. Colonoscopy performed after his last episode of diverticulitis had been unremarkable.
Vital Signs: Temperature 101.5°F, Blood Pressure 130/75 mmHg, Heart Rate 98 beats/min, BMI 31 kg/m2
Labs: Remarkable for WBC 14 and CRP 85.
Imaging: CT AP with contrast confirms a diagnosis of recurrent uncomplicated sigmoid diverticulitis.
How would you manage this patient? (More than one option may be correct)
Outpatient treatment with augmentin (amoxicillin/clavulanate) 875/125mg PO daily
Incorrect! This regimen has gram negative and anaerobic coverage and would be an excellent choice for treating diverticulitis. However since he is febrile and not tolerating orals, he merits admission and treatment with intravenous antibiotics.
Admit and treat with Zosyn (Piperacillin-tazobactam) 3.375 g IV every 6 hours
Correct! This regimen has gram negative and anaerobic coverage and is a great choice.
Admit and treat with Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours
Correct! This regimen has gram negative and anaerobic coverage and is a great choice.
Admit and treat with Meropenam 1g every 8 hours
Try again! While this antibiotic regimen has good gram negative and anaerobic coverage, it should be reserved for patients with severe disease or who have resistant infections
Outpatient treatment with Levofloxacin 750mg po daily
Try again! This antibiotic has good gram negative coverage but does not cover against anaerobes. It should be combined with metronidazole if used to treat diverticulitis. Also given that he is febrile and not tolerating orals, he merits admission and treatment with intravenous antibiotics.
Refer for surgery given recurrent episodes of diverticulitis
A discussion of elective segmental resection for patients with a history of diverticulitis should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits, including quality of life. It should not be advised based on the number of diverticulitis episode.
Plan for repeat colonoscopy 6-8 weeks after symptom resolution
Correct! AGA guidelines recommend that if the colonoscopy has been preformed within the past year, repeat surveillance is not necessary. Given this patient’s last colonoscopy was 3 years ago, repeat surveillance should be recommended to exclude missed colonic neoplasm.
Click Here to move on!
Case 5 Index:
Introduction
Physical Exam
Differential Diagnosis
Diagnostic Testing
Management
GiSIM Home
GI SIM 