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Difficulty: MediumGastroenterology and Hepatology

A 52-year-old woman presents to the emergency department with a 2-day history of left lower quadrant abdominal pain. The pain is constant and described as a dull ache. She reports mild nausea but no vomiting, diarrhea, or hematochezia. Her medical history is unremarkable, and she takes no daily medications. Temperature is 37.3°C (99.1°F), blood pressure is 128/82 mmHg, pulse is 84/min, and respirations are 14/min. Abdominal examination reveals focal tenderness in the left lower quadrant without guarding, rigidity, or rebound tenderness. Bowel sounds are normal. Laboratory testing shows a leukocyte count of 9,500/mm³ with a normal differential. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates wall thickening and peri-colic fat stranding in the sigmoid colon. There is no evidence of an abscess, stricture, fistula, or free intraperitoneal air. The patient is able to tolerate oral fluids without difficulty. Which of the following is the most appropriate next step in management?

  1. Discharge home with a clear liquid diet and supportive careAnswer
  2. B
    Discharge home with a prescription for oral ciprofloxacin and metronidazole
  3. C
    Admit to the hospital for intravenous piperacillin-tazobactam
  4. D
    Consult general surgery for an urgent sigmoid colectomy
  5. E
    Admit for bowel preparation and urgent colonoscopy

Answer

Discharge home with a clear liquid diet and supportive care
The correct answer involves discharging the patient home with a clear liquid diet and supportive care. This patient presents with classic signs of acute uncomplicated diverticulitis, confirmed by a CT scan showing localized inflammation without complications such as an abscess, fistula, or free air. She is hemodynamically stable, afebrile, has a normal white blood cell count, and can tolerate oral intake. According to the American Gastroenterological Association (AGA) and other current societal guidelines, the routine use of antibiotics is no longer recommended for acute uncomplicated diverticulitis in immunocompetent patients without signs of systemic toxicity. Observational management with bowel rest (clear liquid diet) and close follow-up has been shown to be safe and effective, with no significant difference in complication rates, recurrence, or time to recovery compared to antibiotic therapy. This approach aligns with modern principles of antibiotic stewardship.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and imaging findings.
The patient has left lower quadrant pain, normal vital signs, a normal leukocyte count, and CT findings of localized colonic wall thickening and fat stranding without complications.
To establish the diagnosis of acute uncomplicated diverticulitis and determine the severity of the disease.
2
Evaluate the indications for antibiotic therapy in this patient.
The patient is immunocompetent, has no signs of systemic inflammatory response syndrome (SIRS), and has no complications (abscess, perforation) on her CT scan.
To apply current guidelines which distinguish between patients who require antibiotics and those who can be safely managed observationally.
3
Determine the appropriate disposition and management plan.
The patient can tolerate oral intake and has mild disease, making her a candidate for outpatient management with a clear liquid diet and supportive care.
To provide evidence-based care while minimizing the risks of antibiotic resistance and adverse medication effects.

Key Concept

Management of acute uncomplicated diverticulitis
Estimated Time:1m 0s
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Topics

Gastroenterology and Hepatology

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