What is the next step in managing a patient with diverticulitis, presenting with fever, localized left lower quadrant pain, abdominal distention, and lab results indicating inflammation (elevated C-reactive protein) and leukocytosis (elevated white blood cell count)?

Management of Acute Diverticulitis

The next step in the management plan for this 64-year-old male patient with diverticulitis should be NPO, intravenous (IV) fluid resuscitation, and IV antibiotics. 1

Clinical Assessment and Diagnosis

• The patient presents with classic signs of acute diverticulitis: initial diffuse abdominal pain localizing to the left lower quadrant, fever (38.4°C), anorexia, nausea, constipation, and abdominal distention 1, 2
• Laboratory findings show leukocytosis (WBC 12,000) and elevated C-reactive protein (52 mg/L), consistent with inflammatory response in diverticulitis 1
• CT findings of bowel wall thickening and fat stranding are characteristic imaging features of diverticulitis 1, 2
• These clinical, laboratory, and imaging findings together confirm the diagnosis of acute diverticulitis 1

Management Approach

Initial Management

• NPO (nothing by mouth) is necessary to rest the bowel and prevent exacerbation of inflammation 1
• IV fluid resuscitation is essential to correct potential dehydration from fever, poor oral intake, and third-spacing of fluids 1
• IV antibiotics are indicated due to:
  • Presence of fever (38.4°C) suggesting systemic inflammatory response 1
  • Elevated WBC count (12,000) and CRP (52 mg/L) indicating significant inflammation 1, 3
  • CT findings showing bowel wall thickening and fat stranding 1, 2

Antibiotic Selection

• For patients with signs of systemic inflammation, broad-spectrum antibiotics covering gram-negative and anaerobic bacteria are recommended 1, 4
• Appropriate regimens include:
  • Piperacillin/tazobactam 4g/0.5g q6h 1
  • Ertapenem 1g q24h 1
  • Eravacycline 1 mg/kg q12h 1

Rationale Against Other Options

• Surgical consult for exploratory laparoscopy (Option A) is not indicated as the first step since there are no clear signs of perforation, peritonitis, or failure of medical management 1
• Gastric decompression and IV fluids (Option C) alone are insufficient as they do not address the infectious/inflammatory component 1
• Colonoscopy (Option D) is contraindicated during acute diverticulitis as it may worsen inflammation or cause perforation 1, 2

Risk Stratification and Monitoring

• The patient's CRP level (52 mg/L) is below the threshold (170 mg/L) that would suggest complicated diverticulitis requiring more aggressive intervention 3, 5
• Close monitoring is essential for:
  • Vital signs, especially temperature trends 1
  • Serial abdominal examinations to detect worsening tenderness or peritoneal signs 1
  • Laboratory markers including WBC count and CRP 1, 3
  • Clinical response to treatment within 48-72 hours 1, 4

Follow-up Considerations

• If the patient fails to improve with conservative management within 48-72 hours, reassessment with repeat imaging and possible surgical consultation would be warranted 1
• Colonoscopy should be considered 6-8 weeks after resolution of symptoms if the patient has not had a recent high-quality colonoscopy 1
• Patients with ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1