How to manage a patient with uncomplicated diverticulitis?

Management of Uncomplicated Diverticulitis

For a 57-year-old woman with uncomplicated sigmoid diverticulitis confirmed by CT scan, the patient should be discharged home with close follow-up and selective antibiotic therapy only if specific risk factors are present. 1

Assessment and Classification

This patient presents with:

• Left lower abdominal pain
• No fever (temperature 37.2°C)
• No diarrhea or blood in stool
• Mild leukocytosis (WBC 13,000)
• CT showing diverticulitis in sigmoid colon without abscess
• No signs of peritonitis (no rebound tenderness)

Based on these findings, this is a case of uncomplicated diverticulitis, which accounts for approximately 85% of diverticulitis cases 2.

Management Approach

Outpatient Management

Outpatient management is appropriate for this patient because:

• She has uncomplicated diverticulitis (no abscess, perforation, or other complications on CT)
• She has no signs of sepsis (normal temperature, stable vital signs)
• She has no concerning features requiring hospitalization 1

Antibiotic Considerations

• Current guidelines support selective antibiotic use rather than routine antibiotics for uncomplicated diverticulitis 1, 2
• Antibiotics should be reserved for patients with:
  • Persistent fever or chills
  • Increasing leukocytosis (>15 × 10^9/L)
  • Age >80 years
  • Immunocompromised status
  • Significant comorbidities
  • Systemic symptoms 2

This patient has mild leukocytosis but no other concerning features, so observation without antibiotics is appropriate.

Dietary Recommendations

• Clear liquid diet during the acute phase
• Advance diet as symptoms improve 3
• Long-term high-fiber diet is recommended for prevention of recurrence 1

Follow-up Care

• Clinical follow-up within 2-3 days to assess for symptom resolution 1
• Colonoscopy 6-8 weeks after resolution of symptoms to exclude colonic neoplasm (if not performed within the past year) 3, 1

Monitoring for Treatment Failure

The patient should be instructed to return immediately if she develops:

• Persistent or worsening pain
• Development of fever
• Inability to tolerate oral intake
• New or worsening systemic symptoms

Prevention of Recurrence

Advise the patient on preventive measures:

• High-fiber diet (fruits, vegetables, whole grains)
• Regular physical activity
• Smoking cessation (if applicable)
• Avoidance of NSAIDs, opiates, and corticosteroids 1

Pitfalls and Caveats

1. Don't miss complicated diverticulitis: Repeat imaging should be considered if symptoms worsen or don't improve within 2-3 days 1

2. Don't miss colorectal cancer: Colonoscopy after 6-8 weeks is important as malignancy can be misdiagnosed as diverticulitis (1.3% risk in uncomplicated diverticulitis) 3

3. Recognize persistent symptoms: About 45% of patients report periodic abdominal pain at 1-year follow-up, often due to visceral hypersensitivity rather than ongoing inflammation 3

4. Avoid unnecessary hospitalization: Outpatient treatment for uncomplicated diverticulitis has been shown to be safe and effective with lower failure rates compared to inpatient treatment (10% vs 32%) 4