Case Study: Towards the end of your clinic day, your nurse comes up to you in the hallway and asks if you have time to see Robert, one of your long-time patients, for an urgent visit. Robert is a 39-year-old man with a history of obesity, acid reflux, and cigarette smoking, but he has not had any serious illnesses in the past. You agree to see the patient. A few minutes later, you walk into one of the exam rooms and see Robert, in visible discomfort, lying on the examining table. You ask him what is wrong, and he replies:
“Doc, I’ve never had stomach pain this bad in my life.”
You ask Robert for additional details, and he tells you that he has been having sharp pains in his left lower abdomen for two days now. The pain has gotten worse since this morning and is associated with nausea and constipation. The pain is significantly worse with straining. His stools are hard pellets, but he has not seen any blood. He generally smokes two packs per day, but has not smoked much today because of his nausea. Robert has had a long history of constipation and readily admits that he has recently been very busy with a construction job. As a result, he has not been drinking much water, despite the summer heat, and he has only had time to eat fast food.
What do you want to do now?
You take a quick glance at his vital signs and note that Robert is slightly febrile with a temperature of 38.9 degrees Celsius, slightly tachycardic with a heart rate of 110 beats per minute, and has normal blood pressure. His BMI is 35 kg/m2 and unchanged from his previous visit six months earlier. On physical exam, Robert is tender to moderate palpation in the left lower quadrant, but he does not have any signs of peritonitis.
What do you do next?
You decide to obtain imaging and labs. So you send Robert to the local hospital for a complete blood count, basic metabolic panel, and urinalysis. You are suspicious that he has diverticulitis, so you also order a CT scan of his abdomen and pelvis. When you see the lab report, you note that he has an elevated WBC. The read on the CT scan says that he has evidence of diverticulitis without any associated pericolonic fluid collections, obstructions, or large perforations.
As you know, diverticula are outpouchings of the intestinal wall usually caused by increased intraluminal pressure pushing out weakened areas of the bowel wall. Common causes of increased intraluminal pressure include straining due to constipation and obesity. The presence of diverticula is diverticulosis, and inflamed diverticula produce a diagnosis of diverticulitis. Diverticulitis with associated perforation, bleeding, abscess, fistula or obstruction is called complicated diverticulitis. Based on his CT scan and clinical findings, Robert has uncomplicated diverticulitis at this time.
What sort of medical management would you recommend for Robert?
Robert is able to hold down liquids, and his pain is controllable on oral pain medication. He does not need to be admitted to the hospital for serial abdominal exams, intravenous antibiotics, or intravenous pain control. You send him home on a clear liquid diet and a follow-up appointment in 3 days. If his pain or nausea become worse instead of improving over the next few days, he is to go to the local emergency room and request that they call you.
Three days later, he returns to clinic and tells you that he only has mild symptoms and is tolerating his liquid diet. On clinical exam, you observe that he is much less tender to palpation and does not have any signs of peritonitis. You decide that hospitalization is not necessary, but you send him home with ciprofloxacin and metronidazole and tell him to continue his liquid diet. He is to follow up with you in another 3 days unless his symptoms become worse.
The next time you see Robert in clinic, his symptoms have completely resolved. He is completing his course of oral antibiotics but is no longer requiring pain medication. You send him home to finish his antibiotics and slowly advance his diet. You also recommend that he lose weight, stop smoking, increase his fiber and water intake, and start an exercise program.
Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357(20):2057-66.
Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013;87(9):612-20.
Dr. V. Silverstein
Published on 7/8/17