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Difficulty: MediumGastroenterology and Hepatology

A 44-year-old man visits the urgent care clinic complaining of a 3-day history of progressive left lower quadrant abdominal pain. He reports mild nausea but has not vomited. His last bowel movement was yesterday and was normal in consistency. He has no significant past medical history and takes no medications. His temperature is 37.3∘C37.3^\circ\text{C} (99.1∘F99.1^\circ\text{F}), blood pressure is 124/78 mmHg124/78\text{ mmHg}, and pulse is 82/min82/\text{min}. Physical examination reveals focal tenderness to palpation in the left lower quadrant without rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of 9,800/mm39,800/\text{mm}^3. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates wall thickening of the sigmoid colon with adjacent pericolonic fat stranding. There is no evidence of an abscess, stricture, fistula, or free intraperitoneal air. He is able to tolerate oral fluids without difficulty. Which of the following is the most appropriate next step in management?

  1. Discharge home with instructions for a clear liquid diet and clinical observationAnswer
  2. B
    Prescription for a 7-day course of oral amoxicillin-clavulanate
  3. C
    Hospital admission for intravenous ertapenem therapy
  4. D
    Referral for an immediate diagnostic colonoscopy
  5. E
    Consultation for CT-guided percutaneous fluid drainage

Answer

Discharge home with instructions for a clear liquid diet and clinical observation
The correct answer is discharging the patient home with instructions for a clear liquid diet and clinical observation. This patient has acute uncomplicated diverticulitis, characterized by localized colonic inflammation without evidence of complications such as an abscess, perforation, or fistula on CT imaging. He is immunocompetent, hemodynamically stable, lacks systemic toxicity (e.g., normal temperature and leukocyte count), and is able to tolerate oral hydration. Current gastroenterology and surgical guidelines strongly emphasize antibiotic stewardship, recommending conservative management—consisting of a temporary fluid diet, bowel rest, and close outpatient follow-up—without routine antibiotics for this specific population. Extensive studies demonstrate that in mild, uncomplicated cases, omitting antibiotics does not increase the rate of complications, surgical interventions, or recurrence, while successfully avoiding antibiotic-related adverse effects and promoting stewardship.

Step-by-Step Solution

1
Analyze the clinical presentation and imaging findings.
The patient has localized left lower quadrant pain, normal vital signs, normal leukocyte count, and a CT scan showing sigmoid wall thickening without complications.
To establish a definitive diagnosis of acute uncomplicated diverticulitis.
2
Assess the patient's severity and stability.
The patient is hemodynamically stable, immunocompetent, lacks signs of systemic toxicity, and can tolerate oral fluids.
To determine whether the patient requires inpatient admission or can be safely managed in an outpatient setting.
3
Select the most appropriate evidence-based therapy.
Supportive care with a clear liquid diet and close clinical observation without antibiotics.
Current guidelines recommend against the routine use of antibiotics for mild, uncomplicated diverticulitis in healthy patients.

Key Concept

Management of acute uncomplicated diverticulitis emphasizes observation and dietary modification over routine antibiotic therapy in select immunocompetent, stable patients.
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Topics

Gastroenterology and Hepatology

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