Diagnosis: Acute Uncomplicated Diverticulitis, with recurrence
Diverticulitis is the third most common inpatient gastrointestinal diagnosis in the US. Mean age at admission is 63 years and the incidence increases with age. Lifestyle factors associated with increased risk include high dietary red meat, low dietary fiber, lack of vigorous physical activity, smoking (≥40 pack-years), and high BMI (≥25 kg/m2).
Abdominal pain is the most common presenting symptom and is most often localized to the left-lower quadrant due to sigmoid colon involvement. Associated symptoms can include nausea and vomiting (20-62%), constipation (~50%), diarrhea (25-35%), and low grade fever. CT imaging with IV/PO has high sensitivity (94%) and specificity (99%) for making a diagnosis and is also crucial for differentiating uncomplicated from complicated disease (concomitant presence of bowel obstruction, abscess, fistula, or perforation). All patients with complicated disease require admission, while many patients with uncomplicated disease are managed successfully as outpatients. Criteria that warrant inpatient treatment for uncomplicated disease include: Age >70 years, high fever (>102F), peritonitis or severe abdominal pain, per oral intolerance, significant leukocytosis, evidence of microperforation or phlegmon on CT, significant comorbidities and immunosuppressive disorders, inability to return for follow up, and failed outpatient treatment.
Close follow up (within 1 week) and supportive care are the mainstays of early outpatient management of uncomplicated diverticulitis. Antibiotics (7-10 day course with gram negative and anaerobic coverage) should be used selectively in uncomplicated diverticulitis for patients with evidence of severe infection, significant comorbidities, or immunosuppressive conditions. Follow up care for diverticulitis should include colonoscopy 6-8 weeks after recovery to rule out a diagnosis of colonic cancer. Elective colonic resection to minimize disease recurrence is not routinely recommended and should only be performed on an individualized basis after a thorough risks and benefits discussion. Lifestyle modifications associated with reduced risk of disease recurrence include weight loss (normal BMI), high-quality/high-fiber diet, vigorous physical activity, smoking cessation, and limiting NSAID use.
Case authored by: Morgan Goodman MD and Bhavana Bhagya Rao MD
1. Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021 Feb;160(3):906-911.
2. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20.
3. Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019 Apr;156(5):1282-1298.
A special thank you to Dr. Richard Stern for providing us with CT images for this case!