MKSAP: 58-year-old woman with left lower abdominal discomfort

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 58-year-old woman is evaluated in the emergency department for a 2-day history of left lower abdominal discomfort. The pain began insidiously and has gradually progressed. She has felt warm but has not had shaking chills, urinary symptoms such as dysuria or urgency, change in bowel habits, or apparent blood in her stool. She is able to eat and drink normally; however, her appetite is decreased. She has never had symptoms like this before. Her medical history is unremarkable.

On physical examination, temperature is 36.6 °C (97.9 °F), blood pressure is 135/68 mm Hg, pulse rate is 94/min, and respiration rate is 18/min. She appears mildly uncomfortable. Mild left lower quadrant abdominal tenderness is noted, with no fullness or mass, guarding, or rebound tenderness.

Laboratory studies are significant for a hemoglobin level of 11.8 g/dL (118 g/L) and a leukocyte count of 10,800/µL (10.8 × 109/L). Serum electrolyte levels and kidney function studies are normal.

Abdominal CT scan shows inflammation of the sigmoid colon and mesentery consistent with acute diverticulitis; no bowel obstruction or abscess is noted.

In addition to antibiotic therapy, which of the following is the most appropriate management?

A. Discharge home with close follow-up
B. Laparoscopic sigmoid resection
C. Percutaneous drainage
D. Urgent colonoscopy

MKSAP Answer and Critique

The correct answer is A. Discharge home with close follow-up.

The most appropriate management for this woman with diverticulitis is treatment with oral antibiotics with home discharge and close clinical follow-up. The therapeutic approach to diverticulitis is dictated by patient-related factors, the severity of clinical features, and the ability to tolerate oral intake. In a healthy, immunocompetent patient with mild symptoms, outpatient therapy is appropriate and should consist of a liquid diet, oral antimicrobial agents that cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole), and as-needed analgesia. Close follow-up is warranted to detect any deterioration as soon as possible. For older, frail, sicker patients, and in those with potential complications of diverticulitis (such as peritonitis or fistula formation), hospitalization is recommended for administration of intravenous antimicrobial agents and observation. This patient with diverticulitis has mild symptoms and is otherwise healthy. She is able to maintain oral intake and can therefore be managed as an outpatient with oral antibiotics and close follow-up.

Surgery is pursued acutely only in patients who have free perforation or peritonitis, or in those for whom medical therapy is unsuccessful. If indicated, both laparoscopic and open procedures are options; laparoscopic treatment is associated with a more rapid recovery time. This patient does not have a current indication for surgical intervention.

Percutaneous drainage is typically indicated in patients with diverticulitis with larger abscesses (often considered to be >3 cm) that are procedurally amenable in those without evidence of peritonitis. Smaller abscesses are usually treated with antibiotics alone and close follow-up.

This patient does not have evidence of an abscess on imaging; therefore, percutaneous drainage is not indicated.

Colonoscopy is recommended after recovery because diverticulitis may be precipitated by a sigmoid cancer; however, colonoscopy during an attack is contraindicated because it would be very difficult to insert the colonoscope beyond the area of inflammation and obtain adequate mucosal inspection. In addition, it may cause peritonitis.

Key Point

  • In a healthy, immunocompetent patient with diverticulitis and mild symptoms, outpatient therapy is appropriate and should consist of a liquid diet, oral antimicrobial agents that cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole), and as-needed analgesia.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 17 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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