What is the management for a 33-year-old female patient presenting to the Emergency Room (ER) with acute diffuse abdominal pain, nausea, and a history (hx) of diverticulitis, diagnosed with cecal diverticulitis on computed tomography (CT) scan, and indicated for ileocecal resection?

From the Guidelines

Ileocecal resection is not indicated as first-line treatment for this patient with cecal diverticulitis. The 33-year-old female presenting with acute diffuse abdominal pain and nausea, with CT findings of uncomplicated cecal diverticulitis (no abscess or obstruction), should initially be managed conservatively.

Key Considerations

• The patient's symptoms and CT findings are consistent with uncomplicated cecal diverticulitis, which can often be managed without surgery 1.
• The American College of Physicians suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting, which can be applied to this case of cecal diverticulitis as well 1.
• Recommended treatment includes a 7-10 day course of oral antibiotics covering gram-negative and anaerobic bacteria, such as ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily, or amoxicillin-clavulanate 875/125mg twice daily 1.
• The patient should maintain a clear liquid diet initially, advancing as tolerated, with adequate hydration and pain management using acetaminophen or, if needed, tramadol.
• Surgery is typically reserved for complicated cases with perforation, abscess not amenable to drainage, obstruction, or patients who fail medical management with recurrent episodes.
• This conservative approach is preferred because uncomplicated diverticulitis often resolves with antibiotics alone, avoiding unnecessary surgical risks including infection, bleeding, and prolonged recovery time 1.
• Follow-up in 1-2 weeks is recommended to ensure resolution of symptoms.

Rationale

• The principles of diagnosis and treatment of acute right-sided colonic diverticulitis, such as cecal diverticulitis, are similar to those of left-sided colonic diverticulitis 1.
• CT scanning appears to be the best overall imaging modality in the diagnosis of possible cecal diverticulitis, and has been used in this case to confirm the diagnosis 1.
• Non-operative methods should be preferred in cases without diffuse peritonitis, and surgical treatment is usually used in the treatment of complicated cases 1.

From the Research

Patient Presentation

• The patient is a 33-year-old female presenting with acute diffuse abdominal pain associated with nausea, but no vomiting or diarrhea.
• The patient has a history of diverticulitis, and a CT scan shows cecal diverticulitis with no signs of obstruction or abscess formation.

Indications for Surgery

• According to 2, if the diagnosis of cecal diverticulitis is made intraoperatively and malignancy can be securely excluded, ileocecal resection is recommended.
• 3 suggests that operative therapy should be ileocecectomy, and the surgical specimen should be examined during surgery to rule out carcinoma.
• 4 endorses an aggressive operative approach to the management of cecal diverticulitis, with the resection of all clinically apparent disease at the time of the initial operation.
• 5 recommends right hemicolectomy for the hidden variant of cecal diverticulitis, which presents as a large, indurated phlegmon and is difficult to distinguish from a perforated cecal carcinoma.

Treatment Options

• 2 recommends ileocecal resection if the diagnosis is made intraoperatively and malignancy can be excluded.
• 3 suggests ileocecectomy as the operative therapy.
• 4 recommends right hemicolectomy for cases with multiple diverticuli and cecal phlegmon, or when neoplastic disease cannot be excluded.
• 6 concludes that diverticulectomy, if technically feasible, could be considered as adequate therapy for cecal diverticulitis, but aggressive resection should be considered in cases of extensive inflammatory changes.

Specific Case Considerations

• Given the patient's presentation and the CT scan results, ileocecal resection is indicated, as recommended by 2 and 3.
• The patient's age and lack of complications, such as obstruction or abscess formation, support a surgical approach, as suggested by 4 and 5.