What is the workup and management for a 76-year-old female with a past medical history (PMH) of diverticulitis, currently passing stool, who has recently received chemotherapy and experiences worsening symptoms when sitting up and walking?

Workup and Management for a 76-Year-Old Female with Diverticulitis Post-Chemotherapy

For a 76-year-old female with a history of diverticulitis who has recently received chemotherapy and is experiencing worsening symptoms when sitting up and walking, prompt CT imaging and aggressive antibiotic therapy are required due to her immunocompromised status and high risk for complicated diverticulitis.

Initial Workup

• CT scan with IV contrast should be performed immediately to confirm diagnosis and assess for complications, as immunocompromised patients may present with milder symptoms despite having severe disease 1
• If IV contrast is contraindicated (severe kidney disease or contrast allergy), consider non-contrast CT or ultrasound 1
• Complete blood count to assess for leukocytosis (WBC > 15 × 10^9 cells/L indicates higher risk for progression) 1
• C-reactive protein (CRP > 140 mg/L indicates higher risk for progression) 1
• Stool studies including tests for C. difficile, other infectious pathogens, and fecal leukocytes 1
• Electrolyte panel to assess for dehydration 1

Management Approach

Immediate Interventions

• Broad-spectrum antibiotics are mandatory due to:

  • Recent chemotherapy (immunocompromised status) 1
  • Higher risk of progression to complicated diverticulitis 1
  • Increased risk of perforation and death in immunocompromised patients 1

• Antibiotic regimen:

  • Inpatient: IV antibiotics with gram-negative and anaerobic coverage (ceftriaxone plus metronidazole or piperacillin-tazobactam) 1, 2
  • Longer duration of treatment (10-14 days) is recommended for immunocompromised patients 1

• Bowel rest and hydration:

  • Clear liquid diet during acute phase 1
  • IV fluids if unable to maintain oral hydration 1
  • Advance diet as symptoms improve 1

Management of Chemotherapy-Induced Diarrhea (if present)

• For severe diarrhea (grade 3-4):
  • Octreotide (100-150 μg SC TID or IV 25-50 μg/hr if severely dehydrated) 1
  • Hold chemotherapy until symptoms resolve 1
  • Consider loperamide for mild symptoms 1

Monitoring and Follow-up

• Low threshold for surgical consultation due to immunocompromised status 1
• Close monitoring for signs of deterioration or complications 1
• Colonoscopy should be performed 6-8 weeks after resolution of acute symptoms to rule out malignancy 1
• After recovery, consultation with a colorectal surgeon to discuss elective resection should be considered due to her immunocompromised status 1

Special Considerations for This Patient

• Worsening symptoms when sitting up and walking may indicate:

  • Peritoneal irritation from localized inflammation 1
  • Possible abscess formation requiring drainage 1
  • Potential for complicated diverticulitis requiring more aggressive intervention 1

• Recent chemotherapy significantly increases risk for:

  • More severe disease despite milder presenting symptoms 1
  • Progression to complicated diverticulitis 1
  • Perforation and death 1

Prevention of Recurrence

• Dietary modifications:

  • High-fiber diet from fruits, vegetables, whole grains, and legumes 1
  • Avoid red meat and sweets 1
  • Note that nuts, corn, popcorn, and small-seeded fruits are not associated with increased risk 1

• Lifestyle modifications:

  • Maintain normal BMI 1
  • Regular physical activity 1
  • Smoking cessation 1
  • Avoid NSAIDs (except aspirin if prescribed for cardiovascular disease) 1

Common Pitfalls to Avoid

• Underestimating severity in immunocompromised patients who may present with milder symptoms despite having severe disease 1
• Delaying imaging which is crucial for diagnosis and identifying complications in this high-risk patient 1
• Inadequate antibiotic coverage - immunocompromised patients require broader coverage and longer duration (10-14 days) 1
• Failure to consider colorectal cancer as a differential diagnosis, especially in elderly patients 1
• Premature advancement of diet before symptoms improve 1