Diverticulitis...pending

A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable.

A CT of the abdomen/ pelvis with oral and IV contrast was obtained.

CT Scan of Diverticulitis

There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics.

Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home.

What is the next step?

Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis.

The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis.

Management of Diverticulitis

Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2]

Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy.

Indications for Surgery

Emergent surgery- acute episode with perforation or peritonitis.
Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics).
Elective colectomy

- Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction.

- Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc).

For More Information on the Management of Diverticulitis

ASCRS Patient Information: Diverticular Disease