What is the management, diagnosis, and treatment of diverticulitis in a 74-year-old female patient?

From the Guidelines

Management of diverticulitis in a 74-year-old female requires prompt assessment and appropriate treatment based on disease severity, with consideration of her advanced age and potential comorbidities. For uncomplicated diverticulitis, outpatient management with oral antibiotics is recommended, typically amoxicillin-clavulanate 875/125 mg twice daily or ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily for 7-10 days 1. The patient should follow a clear liquid diet initially, gradually advancing to low-fiber foods as symptoms improve. For complicated diverticulitis with abscess, perforation, or peritonitis, hospitalization is necessary with IV antibiotics (such as piperacillin-tazobactam 3.375 g every 6 hours or ceftriaxone 1-2 g daily plus metronidazole 500 mg every 8 hours), bowel rest, and possible surgical intervention. Diagnosis relies on clinical presentation (left lower quadrant pain, fever, altered bowel habits), laboratory tests (elevated white blood cell count, CRP), and imaging (CT scan is preferred) 1. After acute episode resolution, colonoscopy should be performed 6-8 weeks later to exclude malignancy, especially in this age group. Long-term management includes high-fiber diet (25-30g daily), adequate hydration, regular physical activity, and weight management. Given her advanced age, careful monitoring for complications and medication side effects is essential, with consideration of comorbidities when selecting antibiotics. Some key points to consider in management include:

• The use of antibiotics can be selective, rather than routine, in immunocompetent patients with mild acute uncomplicated diverticulitis 1.
• Outpatient management is suitable for most patients with acute uncomplicated diverticulitis, with hospitalization reserved for those with complicated disease or significant comorbidities 1.
• CT imaging is recommended for diagnostic uncertainty, with abdominal ultrasonography or magnetic resonance imaging considered as alternatives in certain cases 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life, with consideration of the patient's individual circumstances and preferences. In this case, the patient's advanced age and potential comorbidities should be carefully considered when selecting treatment options, with a focus on minimizing risks and optimizing outcomes 1.

From the Research

Diagnosis of Diverticulitis

• Diverticulitis should be suspected in patients with isolated left lower quadrant pain, abdominal distention or rigidity, fever, and leukocytosis 2
• Initial laboratory workup includes a complete blood count, basic metabolic panel, urinalysis, and C-reactive protein measurement 2
• Computed tomography with intravenous contrast is the preferred imaging modality to confirm diagnosis and assess for complications of diverticulitis 2, 3

Treatment of Diverticulitis

• Treatment decisions are based on the categorization of disease as complicated vs. uncomplicated 2
• Selected patients with uncomplicated diverticulitis may be treated without antibiotics 4, 2
• Complicated diverticulitis is treated in the hospital with modified diet or bowel rest, antibiotics, and pain control 2
• Abscesses that are 3 cm or larger should be treated with percutaneous drainage 2

Management of Diverticulitis in Older Adults

• Older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients 5
• Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging 5
• Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment 5

Surgical Management

• Surgical intervention appears to improve patient’s quality of life 3
• The decision to proceed with surgery is recommended in an individualized manner 3
• Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment 3
• For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis 3

Case-Specific Management

• A 74-year-old female patient with a history of diverticulosis and diverticulitis, who developed perforated sigmoid diverticulitis and underwent laparoscopic washout, may require surgical resection of the sigmoid colon if a giant diverticulum develops as a complication 6