Surgery

60 year old man presenting with left lower quadrant abdominal pain

Maia Anderson on Jan 23, 2017

A 60 year old man presents to the ED with a 3 day history of left lower quadrant abdominal pain, nausea, and fever. The pain started a few nights ago after dinner and has not improved with Tylenol or Tums. He describes the pain as 6/10 non-radiating crampy pain, predominantly in the left lower quadrant. He also reports a few loose stools and dysuria. He has not noticed any blood in his stools or urine and denies any episodes of vomiting. He has been able to stay hydrated despite his nausea.

His past medical history includes hypertension (well-controlled per the patient) and a right inguinal hernia, which was repaired electively four years ago. He denies other surgeries. He takes hydrochlorothiazide 25mg once daily for his high blood pressure and occasional ibuprofen for back pain. He has no family history of IBD, IBS, or malignancy. The patient reports drinking 2-3 beers per week and has a 30-pack year smoking history (he quit 2 years ago). Review of systems is negative except as above.

On physical exam, his vitals are: Temp 38.4 C HR 90 BP 145/90 RR 14 O2 98% on room air. Cardiovascular and pulmonary exams are unremarkable. His abdomen is non-distended with a well-healed scar from a previous right inguinal hernia repair. Bowel sounds are present. There are no appreciable masses or bulges. There is moderate tenderness to palpation in the LLQ. There is no tenderness at McBurney's point and a negative Murphy's sign. There is no rebound tenderness or guarding. There is no CVAT. Rectal/GU exam is unremarkable. FOBT is negative.

You send for a CBC, BMP, and urinalysis. CBC is remarkable for WBC 12.1 and U/A reveals 5-10 WBC/hpf, no bacteria seen.  

At this point, what is in your differential diagnosis?

Expand all answers
Appendicitis
Less likely - Appendicitis classically present with periumbilical pain that migrates to the RLQ (not LLQ). The patient's age and physical exam also argues against appendicitis.


Infectious colitis
Possibly - Infectious colitis typically presents with diarrhea predominantly. This patient has had a few "loose stools," but primarily complains of pain. He also lacks risk factors for infectious colitis (i.e. prior antibiotic use, recent travel, sick contacts).


IBD
Possibly - IBD typically presents with diarrhea predominantly. This patient has had a few "loose stools," but primarily complains of pain. In addition, the acute rather than chronic time course of this patient's presentation makes IBD less likely - in addition to the lack of family history or systemic manifestations of IBD.


Diverticulitis
Most likely - The patient, a 60 year old man, presents with a classic story for diverticulitis: acute onset LLQ abdominal pain, fever, and leukocytosis). Further testing is required to confirm the diagnosis.


Ischemic colitis
Maybe - Patients with ischemic colitis usually present with bloody stools/diarrhea. This patient denies any blood in his stool and has a negative FOBT. However, this patient does have risk factors (HTN, older age, male, history of smoking).


Inguinal hernia
No - While the patient has a history of a right sided inguinal hernia repair, there is no evidence of hernia on physical exam.


Small bowel obstruction
Unlikely - While the patient has had prior surgery (a major cause of SBO), the patient has been able to tolerate oral intake and is passing stool, making an SBO much less likely.


Colorectal cancer
Possibly - Colorectal cancer can present with acute diverticulitis. This patient has risk factors (age, smoking history). This is something that must be ruled out during his evaluation. It would be important to ask the patient about prior colonoscopies.


  1. Hammond NA, Nikolaidis P, Miller FH. Left lower-quadrant pain: guidelines from the American College of Radiology appropriateness criteria. Am Fam Physician. 2010 Oct 1;82(7):766-70.
  2. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20.

Based on the history and physical exam, you suspect that the patient likely has acute diverticulitis. Which of the following imaging studies would you order to confirm your diagnosis?

Expand all answers
CT abdomen
Yes - Abdominal CT with IV and PO contrast is the current standard for diagnosis of acute diverticulitis (SE: 94%, SP: 99%). CT not only provides accurate diagnosis of diverticulitis (or alternate pathology), but can also identify complications of diverticulitis (i.e. abscess, perforation, fistula, obstruction) - which guides medical and/or surgical management. Ultrasound and MRI are potential alternatives in patients with contraindications to CT (i.e. pregnancy) or allergies to IV contrast.


MRI abdomen
Maybe - MRI has good sensitivity and specificity (94% and 92% respectively) for diverticulitis. MRI has the advantage of avoiding radiation exposure, however, MRI has not been compared to CT scan directly in accuracy and cost-effectiveness for the diagnosis and evaluation of diverticulitis.


Trans-abdominal high resolution ultrasound
Maybe - High-resolution, graded, compression ultrasound has been compared directly to CT scan in acute diverticulitis. Ultrasound was found to be equally efficacious in the diagnosis of acute diverticulitis, but CT was superior in the ability to identify other etiologies of abdominal pain.


Colonoscopy
No - Colonoscopy cannot visualize peridiverticular inflammation and is therefore not useful in the diagnosis of diverticulitis. Further, colonoscopy should not be used in the setting of acute diverticulitis due to risk of perforation or exacerbation of disease. Colonoscopy is, however, recommended to rule out underlying malignancy after resolution of acute diverticulitis (generally ~6 weeks).


  1. Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum. 2008;51:1810–1815.
  2. Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol. 2008 Nov;18(11):2498-511. Epub 2008 Jun 4.
  3. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  4. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  5. Hammond NA, Nikolaidis P, Miller FH. Left lower-quadrant pain: guidelines from the American College of Radiology appropriateness criteria. Am Fam Physician. 2010 Oct 1;82(7):766-70.

You obtain a CT abdomen/pelvis with IV and PO contrast, which shows localized bowel wall thickening and fat stranding. There is no evidence of perforation or fluid collection.

You diagnose the patient with acute uncomplicated diverticulitis. What is your recommendation for management?

Expand all answers
The patient can be treated as an outpatient. Send the patient home with a 10 day course of oral antibiotics, and follow-up with his PCP in 2-3 days.
Maybe - Uncomplicated acute diverticulitis can be safely and effectively treated on an outpatient basis for the majority of patients. Indications for inpatient treatment include inability to tolerate oral intake, significant comorbidities, and lack of family support. Complicated diverticulitis (abscess, fistula, obstruction, perforation) is considered a criteria for inpatient treatment. The use of antibiotics in acute uncomplicated diverticulitis is no longer routinely recommended. See the explanation for "


The patient does not need additional treatment. Send the patient home and advise close follow-up with his PCP.
Maybe - A recent RCT and systematic review found no clear benefit of routine antibiotic use in acute uncomplicated diverticulitis. Despite the traditional use of antibiotics to treat uncomplicated diverticulitis, the decision to treat with antibiotics should be made on an individual basis.


The patient needs inpatient medical treatment. Admit the patient for IV antibiotics, IV fluids, and observation.
No - this patient does not require inpatient treatment. He does not meet the current criteria for inpatient treatment of diverticulitis (complicated diverticulitis, significant comorbidities, inability to tolerate oral intake, lack of family support).


This patient needs urgent surgical intervention. Call a surgery consult for further evaluation.
No - this patient does not require surgical intervention at this time. Criteria for urgent/emergent surgery includes frank perforation, failure of medical/non-operative treatment, obstruction, and potentially abscess. Elective surgery after resolution of an acute episode is discussed later in this case.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Etzioni DA, Chiu VY, Cannom RR, Burchette RJ, Haigh PI, Abbas MA. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum. 2010 Jun;53(6):861-5.
  3. Alonso, S., Pera, M., Parés, D., Pascual, M., Gil, M. J., Courtier, R. and Grande, L. (2010), Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Disease, 12: e278–e282. doi:10.1111/j.1463-1318.2009.02122.x
  4. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539.
  5. Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092.
  6. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

You send the patient home with a 10 day course of ciprofloxacin and metronidazole. Three days later, during his follow-up visit with his PCP, the patient reports no improvement in his abdominal pain or fever. He has been taking his antibiotics as prescribed.
What is your recommendation for further management?

Expand all answers
The patient has inappropriate antibiotic coverage, change his regimen to amoxicillin-clauvanate.
No - the patient's current regimen (cipro and metronidazole) provides adequate coverage of GNRs and anaerobes.


The patient has failed outpatient management, admit the patient for IV antibiotics and further evaluation.
Yes - the patient has persistent abdominal pain and fevers despite adequate antibiotic coverage - he may have complicated diverticulitis. He should be admitted for inpatient treatment.


Reassure the patient that this is a normal time course for recovery. He should expect improvement in his symptoms after a few more days of antibiotics. He does not need additional treatment unless his symptoms worsen or he is unable to tolerate oral intake.
No - this is not an expected time course for recovery. The persistent abdominal pain and fevers suggest that he has failed outpatient treatment and he needs further evaluation and treatment as an inpatient.


  1. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  2. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.

The patient is admitted to the hospital and a repeat CT scan reveals a confined pericolic abscess. Your suspicion of complicated diverticulitis is confirmed. What is your treatment plan?

Expand all answers
Call for a general surgery consult, the patient needs emergent surgery.
No - while the patient has complicated diverticulitis, he does not meet the criteria for urgent/emergent surgery. Urgent sigmoid colectomy is recommended for patients with diffuse peritonitis or patients who fail inpatient non-operative management of acute diverticulitis.


Call for an IR consult, the patient needs percutaneous drainage of the abscess and IV antibiotics.
Maybe - Percutaneous drainage of diverticular abscesses remains controversial. The recommendation depends primarily on size of abscess and the patient's clinical improvement. Studies suggest that small abscesses (up to 4 cm) should be managed with antibiotics alone, as they will resolve without intervention. In contrast, patients with larger abscesses (diameter >6.5cm) and those who do not clinically improve after ~48 hours should undergo percutaneous drain placement for source control.


Admit the patient for IV antibiotics and observation only at this time.
Maybe - It depends on the size of the abscess. It is generally recommended that stable patients with large diverticular abscesses undergo image-guided percutaneous drainage in addition to IV antibiotics.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  3. Kumar RR, Kim JT, Haukoos JS, et al. Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis Colon Rectum. 2006;49:183–189
  4. Brandt D, Gervaz P, Durmishi Y, et al. Percutaneous CT scan-guided drainage versus antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum. 2006;49:1533–1538

You go back and look at the results of the CT scan - the abscess measures 6.5 cm in greatest dimension. The patient is treated with IV antibiotics and percutaneous drainage of the abscess. He tolerates the procedure well and is discharged after an uneventful hospital course. You see the patient in clinic 3 weeks after discharge. He asks if there is anything he can do to prevent future recurrences of diverticulitis. Which of the following do you recommend?

Expand all answers
High fiber diet
Yes - While there is no definitive evidence that increased fiber intake reduces the risk of recurrent diverticulitis, it has been shown that fiber reduces the risk of symptomatic diverticulitis in patients without a prior history of diverticulitis. Therefore, it is reasonable to recommend a high fiber diet as long as the patient can tolerate possible side effects (i.e. bloating).


Avoid eating nuts, popcorn, and seeds.
No - There is very little data to suggest that consumption of nuts and popcorn increases risk of diverticulitis.


Mesalamine
No - There is no evidence that mesalamine reduces the risk of recurrence, decreases the need for surgery, or aids in the resolution of pain in acute diverticulitis.


Decrease NSAID use
Probably - There is some data to suggest that NSAIDs moderately increase the risk of uncomplicated diverticulitis and complicated diverticulitis.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Raskin, Jeffrey B. et al. Mesalamine Did Not Prevent Recurrent Diverticulitis in Phase 3 Controlled Trials. Gastroenterology , Volume 147 , Issue 4 , 793 – 802. http://dx.doi.org/10.1053/j.gastro.2014.07.004
  3. Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907.
  4. Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011;140(5):1427.

Based on your recommendations, the patient decides he is going to try to incorporate more fiber into his diet and will avoid taking NSAIDs for his back pain. Before he leaves, he wants to know if he needs any more studies or treatment now that he has recovered from his acute episode of diverticulitis. What do you recommend?

Expand all answers
He is asymptomatic and otherwise healthy. No further studies or treatment are recommended at this time.
No - choose another answer.


Schedule a colonoscopy in 3 to 5 weeks to rule out other diagnoses.
Yes - After resolution of the first episode of acute diverticulitis, a colonoscopy is generally recommended to rule out possible underlying malignancy and other causes etiologies of colonic inflammation (i.e. IBD, ischemic colitis). This is typically performed 6-8 weeks after resolution of the acute episode unless the patient has recently undergone colonoscopy.


Refer the patient for elective colectomy - he is at increased risk of complications and recurrent disease.
Yes - Elective colectomy should be considered after resolution of complicated diverticulitis. This recommendation is based on studies that report a greater risk of complications and mortality in recurrent attacks in patients with prior complicated diverticulitis. In contrast, elective colectomy is not routinely recommended after an episode of uncomplicated diverticulitis, even after multiple recurrences. Studies show that patients with multiple recurrent episodes of uncomplicated disease have no increased risk for morbidity and mortality.


  1. Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014 Feb;259(2):263-72
  2. Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM. Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications. Dis Colon Rectum. 2016 Mar;59(3):208-15.
  3. Regenbogen SE, Hardiman KM1, Hendren S1, Morris AM1.Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg. 2014 Mar;149(3):292-303. doi: 10.1001/jamasurg.2013.5477.
  4. Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA. Patterns of recurrence in patients with acute diverticulitis. Br J Surg. 2010;97:952–957. 42.
  5. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  6. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

A 60 year old man presents to the ED with a 3 day history of left lower quadrant abdominal pain, nausea, and fever. The pain started a few nights ago after dinner and has not improved with Tylenol or Tums. He describes the pain as 6/10 non-radiating crampy pain, predominantly in the left lower quadrant. He also reports a few loose stools and dysuria. He has not noticed any blood in his stools or urine and denies any episodes of vomiting. He has been able to stay hydrated despite his nausea.

His past medical history includes hypertension (well-controlled per the patient) and a right inguinal hernia, which was repaired electively four years ago. He denies other surgeries. He takes hydrochlorothiazide 25mg once daily for his high blood pressure and occasional ibuprofen for back pain. He has no family history of IBD, IBS, or malignancy. The patient reports drinking 2-3 beers per week and has a 30-pack year smoking history (he quit 2 years ago). Review of systems is negative except as above.

On physical exam, his vitals are: Temp 38.4 C HR 90 BP 145/90 RR 14 O2 98% on room air. Cardiovascular and pulmonary exams are unremarkable. His abdomen is non-distended with a well-healed scar from a previous right inguinal hernia repair. Bowel sounds are present. There are no appreciable masses or bulges. There is moderate tenderness to palpation in the LLQ. There is no tenderness at McBurney's point and a negative Murphy's sign. There is no rebound tenderness or guarding. There is no CVAT. Rectal/GU exam is unremarkable. FOBT is negative.

You send for a CBC, BMP, and urinalysis. CBC is remarkable for WBC 12.1 and U/A reveals 5-10 WBC/hpf, no bacteria seen.  

At this point, what is in your differential diagnosis?

Expand all answers
Appendicitis
Less likely - Appendicitis classically present with periumbilical pain that migrates to the RLQ (not LLQ). The patient's age and physical exam also argues against appendicitis.


Infectious colitis
Possibly - Infectious colitis typically presents with diarrhea predominantly. This patient has had a few "loose stools," but primarily complains of pain. He also lacks risk factors for infectious colitis (i.e. prior antibiotic use, recent travel, sick contacts).


IBD
Possibly - IBD typically presents with diarrhea predominantly. This patient has had a few "loose stools," but primarily complains of pain. In addition, the acute rather than chronic time course of this patient's presentation makes IBD less likely - in addition to the lack of family history or systemic manifestations of IBD.


Diverticulitis
Most likely - The patient, a 60 year old man, presents with a classic story for diverticulitis: acute onset LLQ abdominal pain, fever, and leukocytosis). Further testing is required to confirm the diagnosis.


Ischemic colitis
Maybe - Patients with ischemic colitis usually present with bloody stools/diarrhea. This patient denies any blood in his stool and has a negative FOBT. However, this patient does have risk factors (HTN, older age, male, history of smoking).


Inguinal hernia
No - While the patient has a history of a right sided inguinal hernia repair, there is no evidence of hernia on physical exam.


Small bowel obstruction
Unlikely - While the patient has had prior surgery (a major cause of SBO), the patient has been able to tolerate oral intake and is passing stool, making an SBO much less likely.


Colorectal cancer
Possibly - Colorectal cancer can present with acute diverticulitis. This patient has risk factors (age, smoking history). This is something that must be ruled out during his evaluation. It would be important to ask the patient about prior colonoscopies.


  1. Hammond NA, Nikolaidis P, Miller FH. Left lower-quadrant pain: guidelines from the American College of Radiology appropriateness criteria. Am Fam Physician. 2010 Oct 1;82(7):766-70.
  2. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20.

Based on the history and physical exam, you suspect that the patient likely has acute diverticulitis. Which of the following imaging studies would you order to confirm your diagnosis?

Expand all answers
CT abdomen
Yes - Abdominal CT with IV and PO contrast is the current standard for diagnosis of acute diverticulitis (SE: 94%, SP: 99%). CT not only provides accurate diagnosis of diverticulitis (or alternate pathology), but can also identify complications of diverticulitis (i.e. abscess, perforation, fistula, obstruction) - which guides medical and/or surgical management. Ultrasound and MRI are potential alternatives in patients with contraindications to CT (i.e. pregnancy) or allergies to IV contrast.


MRI abdomen
Maybe - MRI has good sensitivity and specificity (94% and 92% respectively) for diverticulitis. MRI has the advantage of avoiding radiation exposure, however, MRI has not been compared to CT scan directly in accuracy and cost-effectiveness for the diagnosis and evaluation of diverticulitis.


Trans-abdominal high resolution ultrasound
Maybe - High-resolution, graded, compression ultrasound has been compared directly to CT scan in acute diverticulitis. Ultrasound was found to be equally efficacious in the diagnosis of acute diverticulitis, but CT was superior in the ability to identify other etiologies of abdominal pain.


Colonoscopy
No - Colonoscopy cannot visualize peridiverticular inflammation and is therefore not useful in the diagnosis of diverticulitis. Further, colonoscopy should not be used in the setting of acute diverticulitis due to risk of perforation or exacerbation of disease. Colonoscopy is, however, recommended to rule out underlying malignancy after resolution of acute diverticulitis (generally ~6 weeks).


  1. Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum. 2008;51:1810–1815.
  2. Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol. 2008 Nov;18(11):2498-511. Epub 2008 Jun 4.
  3. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  4. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  5. Hammond NA, Nikolaidis P, Miller FH. Left lower-quadrant pain: guidelines from the American College of Radiology appropriateness criteria. Am Fam Physician. 2010 Oct 1;82(7):766-70.

You obtain a CT abdomen/pelvis with IV and PO contrast, which shows localized bowel wall thickening and fat stranding. There is no evidence of perforation or fluid collection.

You diagnose the patient with acute uncomplicated diverticulitis. What is your recommendation for management?

Expand all answers
The patient can be treated as an outpatient. Send the patient home with a 10 day course of oral antibiotics, and follow-up with his PCP in 2-3 days.
Maybe - Uncomplicated acute diverticulitis can be safely and effectively treated on an outpatient basis for the majority of patients. Indications for inpatient treatment include inability to tolerate oral intake, significant comorbidities, and lack of family support. Complicated diverticulitis (abscess, fistula, obstruction, perforation) is considered a criteria for inpatient treatment. The use of antibiotics in acute uncomplicated diverticulitis is no longer routinely recommended. See the explanation for "


The patient does not need additional treatment. Send the patient home and advise close follow-up with his PCP.
Maybe - A recent RCT and systematic review found no clear benefit of routine antibiotic use in acute uncomplicated diverticulitis. Despite the traditional use of antibiotics to treat uncomplicated diverticulitis, the decision to treat with antibiotics should be made on an individual basis.


The patient needs inpatient medical treatment. Admit the patient for IV antibiotics, IV fluids, and observation.
No - this patient does not require inpatient treatment. He does not meet the current criteria for inpatient treatment of diverticulitis (complicated diverticulitis, significant comorbidities, inability to tolerate oral intake, lack of family support).


This patient needs urgent surgical intervention. Call a surgery consult for further evaluation.
No - this patient does not require surgical intervention at this time. Criteria for urgent/emergent surgery includes frank perforation, failure of medical/non-operative treatment, obstruction, and potentially abscess. Elective surgery after resolution of an acute episode is discussed later in this case.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Etzioni DA, Chiu VY, Cannom RR, Burchette RJ, Haigh PI, Abbas MA. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum. 2010 Jun;53(6):861-5.
  3. Alonso, S., Pera, M., Parés, D., Pascual, M., Gil, M. J., Courtier, R. and Grande, L. (2010), Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Disease, 12: e278–e282. doi:10.1111/j.1463-1318.2009.02122.x
  4. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539.
  5. Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092.
  6. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

You send the patient home with a 10 day course of ciprofloxacin and metronidazole. Three days later, during his follow-up visit with his PCP, the patient reports no improvement in his abdominal pain or fever. He has been taking his antibiotics as prescribed.
What is your recommendation for further management?

Expand all answers
The patient has inappropriate antibiotic coverage, change his regimen to amoxicillin-clauvanate.
No - the patient's current regimen (cipro and metronidazole) provides adequate coverage of GNRs and anaerobes.


The patient has failed outpatient management, admit the patient for IV antibiotics and further evaluation.
Yes - the patient has persistent abdominal pain and fevers despite adequate antibiotic coverage - he may have complicated diverticulitis. He should be admitted for inpatient treatment.


Reassure the patient that this is a normal time course for recovery. He should expect improvement in his symptoms after a few more days of antibiotics. He does not need additional treatment unless his symptoms worsen or he is unable to tolerate oral intake.
No - this is not an expected time course for recovery. The persistent abdominal pain and fevers suggest that he has failed outpatient treatment and he needs further evaluation and treatment as an inpatient.


  1. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  2. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.

The patient is admitted to the hospital and a repeat CT scan reveals a confined pericolic abscess. Your suspicion of complicated diverticulitis is confirmed. What is your treatment plan?

Expand all answers
Call for a general surgery consult, the patient needs emergent surgery.
No - while the patient has complicated diverticulitis, he does not meet the criteria for urgent/emergent surgery. Urgent sigmoid colectomy is recommended for patients with diffuse peritonitis or patients who fail inpatient non-operative management of acute diverticulitis.


Call for an IR consult, the patient needs percutaneous drainage of the abscess and IV antibiotics.
Maybe - Percutaneous drainage of diverticular abscesses remains controversial. The recommendation depends primarily on size of abscess and the patient's clinical improvement. Studies suggest that small abscesses (up to 4 cm) should be managed with antibiotics alone, as they will resolve without intervention. In contrast, patients with larger abscesses (diameter >6.5cm) and those who do not clinically improve after ~48 hours should undergo percutaneous drain placement for source control.


Admit the patient for IV antibiotics and observation only at this time.
Maybe - It depends on the size of the abscess. It is generally recommended that stable patients with large diverticular abscesses undergo image-guided percutaneous drainage in addition to IV antibiotics.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.
  3. Kumar RR, Kim JT, Haukoos JS, et al. Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis Colon Rectum. 2006;49:183–189
  4. Brandt D, Gervaz P, Durmishi Y, et al. Percutaneous CT scan-guided drainage versus antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum. 2006;49:1533–1538

You go back and look at the results of the CT scan - the abscess measures 6.5 cm in greatest dimension. The patient is treated with IV antibiotics and percutaneous drainage of the abscess. He tolerates the procedure well and is discharged after an uneventful hospital course. You see the patient in clinic 3 weeks after discharge. He asks if there is anything he can do to prevent future recurrences of diverticulitis. Which of the following do you recommend?

Expand all answers
High fiber diet
Yes - While there is no definitive evidence that increased fiber intake reduces the risk of recurrent diverticulitis, it has been shown that fiber reduces the risk of symptomatic diverticulitis in patients without a prior history of diverticulitis. Therefore, it is reasonable to recommend a high fiber diet as long as the patient can tolerate possible side effects (i.e. bloating).


Avoid eating nuts, popcorn, and seeds.
No - There is very little data to suggest that consumption of nuts and popcorn increases risk of diverticulitis.


Mesalamine
No - There is no evidence that mesalamine reduces the risk of recurrence, decreases the need for surgery, or aids in the resolution of pain in acute diverticulitis.


Decrease NSAID use
Probably - There is some data to suggest that NSAIDs moderately increase the risk of uncomplicated diverticulitis and complicated diverticulitis.


  1. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  2. Raskin, Jeffrey B. et al. Mesalamine Did Not Prevent Recurrent Diverticulitis in Phase 3 Controlled Trials. Gastroenterology , Volume 147 , Issue 4 , 793 – 802. http://dx.doi.org/10.1053/j.gastro.2014.07.004
  3. Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907.
  4. Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011;140(5):1427.

Based on your recommendations, the patient decides he is going to try to incorporate more fiber into his diet and will avoid taking NSAIDs for his back pain. Before he leaves, he wants to know if he needs any more studies or treatment now that he has recovered from his acute episode of diverticulitis. What do you recommend?

Expand all answers
He is asymptomatic and otherwise healthy. No further studies or treatment are recommended at this time.
No - choose another answer.


Schedule a colonoscopy in 3 to 5 weeks to rule out other diagnoses.
Yes - After resolution of the first episode of acute diverticulitis, a colonoscopy is generally recommended to rule out possible underlying malignancy and other causes etiologies of colonic inflammation (i.e. IBD, ischemic colitis). This is typically performed 6-8 weeks after resolution of the acute episode unless the patient has recently undergone colonoscopy.


Refer the patient for elective colectomy - he is at increased risk of complications and recurrent disease.
Yes - Elective colectomy should be considered after resolution of complicated diverticulitis. This recommendation is based on studies that report a greater risk of complications and mortality in recurrent attacks in patients with prior complicated diverticulitis. In contrast, elective colectomy is not routinely recommended after an episode of uncomplicated diverticulitis, even after multiple recurrences. Studies show that patients with multiple recurrent episodes of uncomplicated disease have no increased risk for morbidity and mortality.


  1. Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014 Feb;259(2):263-72
  2. Devaraj B, Liu W, Tatum J, Cologne K, Kaiser AM. Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications. Dis Colon Rectum. 2016 Mar;59(3):208-15.
  3. Regenbogen SE, Hardiman KM1, Hendren S1, Morris AM1.Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg. 2014 Mar;149(3):292-303. doi: 10.1001/jamasurg.2013.5477.
  4. Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA. Patterns of recurrence in patients with acute diverticulitis. Br J Surg. 2010;97:952–957. 42.
  5. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.
  6. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94.

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