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MKSAP 18 "Quiz Me!" Question: Answer and Critique

Answer

C: Oral antibiotics

Educational Objective

Treat uncomplicated diverticulitis.

Critique

The patient has uncomplicated diverticulitis that can be managed with oral antibiotics. Approximately 5% of patients with diverticula will experience an episode of diverticulitis. Symptoms include abdominal pain, fever, and altered bowel habits. Physical examination findings include fever, left-lower-quadrant tenderness, and/or a lower abdominal or rectal mass. If clinical features are highly suggestive of diverticulitis, imaging studies are unnecessary. If the diagnosis is not clear or if an abscess is suspected (severe pain, high fever, palpable mass), CT imaging is indicated. Although the use of a 7-day course of oral antibiotics does not shorten the clinical course of diverticulitis, it may prevent complications from diverticulitis, such as an abscess, and may help prevent a future episode of diverticulitis. The antimicrobial agents used should cover colonic organisms and include anaerobic coverage (such as ciprofloxacin and metronidazole). Treatment can be done on an outpatient basis with close monitoring, and the patient should adhere to a liquid diet for 2 to 3 days, then advance the diet as tolerated. The routine use of antibiotics in uncomplicated diverticulitis has been questioned because of overuse of antibiotics.

Colonoscopy should not be done during acute diverticulitis due to the risk for perforation. In patients who have not undergone screening colonoscopy within the past 3 years, colonoscopy should be done 4 to 8 weeks after resolution of symptoms to exclude colon malignancy.

Intravenous antibiotics are appropriate in patients who cannot take oral medications or who have complicated diverticulitis, such as abscess or fistula formation. Fistulas may form between the colon and other adjacent structures including the bladder, vagina, skin, or peritoneum. CT-guided percutaneous drainage of abscesses is preferred.

Surgery is required for diverticulitis complicated by peritonitis and may be lifesaving. Patients with recurrent diverticulitis may also benefit from surgical resection of the affected area of the colon.

Key Point

Patients with uncomplicated diverticulitis should be treated conservatively with oral antibiotics.

Bibliogrpahy

Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute technical review on the management of acute diverticulitis. Gastroenterology. 2015;149:1950-1976.e12. doi:10.1053/j.gastro.2015.10.001

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