A. 66-ycar-old man is evaiuated because of severe left lower quadrant pain. This morning he awoke with progressive lower abdominal pain. He described both a steady lower abdominal discomfort as well as waves of pain that came in "spasms." Physical examination reveals a man in considerable abdominal distress. His temperature is 38.7 °C (101.5 °F), blood pressure is 160/88 mm Hg, and pulse rate is 108/min. He has occasional, high-pitched bowel sounds, and he is quite tender over the left lower quadrant. The remainder of the examination is normal. Laboratory abnormalities include a hemoglobin of 16 g/dL; leukocyte count of 12,600/pL with 15% band forms and 52% polymorphonuclear cells. A computed tomographic (CT) scan shows several air-filled loops of small intestine. There are multiple diverticula in the left colon, with thickening of wall anc an inflammatory mass but no definite abscess. Which of the following is the most appropriate management? A. CT-guided biopsy of the inflammatory mass B. Laparotomy and colon resection C. Nasogastric suction and an antibiotic D. ColonoscopY
acute diverticulitis management antibiotics bowel rest guidelines
Answer: C - Nasogastric Suction and an Antibiotic
Diagnosis: Acute Diverticulitis (Hinchey Stage Ib/II - Phlegmon)
| Finding | Significance |
|---|---|
| 66-year-old male | Age group most affected |
| Left lower quadrant pain, progressive | Classic sigmoid diverticulitis location |
| Fever 38.7°C, tachycardia 108/min | Systemic inflammatory response |
| WBC 12,600 + 15% band forms | Leukocytosis with left shift (infection/inflammation) |
| CT: diverticula + wall thickening + inflammatory mass | Hinchey Stage Ib - pericolic phlegmon (no free abscess, no free air) |
| High-pitched bowel sounds, dilated small bowel loops | Reactive ileus from adjacent inflammation |
Why C is Correct
"Conservative treatment of acute diverticulitis normally includes bowel rest with intravenous fluids, antibiotics, and appropriate analgesia." - Yamada's Textbook of Gastroenterology
"A patient with localized LLQ peritonitis secondary to sigmoid colonic diverticulitis can be managed with bowel rest and IV antibiotics alone." - Sleisenger and Fordtran's GI and Liver Disease
Why the Other Options Are Wrong
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A. CT-guided biopsy - There is no indication for biopsy here. The diagnosis is clinically clear. Biopsy of an acute inflammatory mass risks perforation, fistula, or spreading infection. Biopsy is considered only if malignancy cannot be excluded after the acute episode resolves (via colonoscopy at ~6 weeks).
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B. Laparotomy and colon resection - Surgery is reserved for complicated diverticulitis: free perforation with peritonitis (Hinchey III/IV), failure of medical management, or large undrained abscesses. This patient has a phlegmon (not a frank abscess), no free perforation, and no peritonitis - surgery is premature here.
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D. Colonoscopy - Colonoscopy is contraindicated in acute diverticulitis. Insufflating a bowel with active inflammation and wall weakening risks perforation. Colonoscopy is done electively 6-8 weeks after resolution to rule out underlying carcinoma (especially since carcinoma can mimic diverticulitis on CT).
Clinical Pearls
- A phlegmon (inflammatory mass without a discrete fluid collection) responds well to conservative medical management in the majority of cases.
- If a discrete abscess >4 cm were present instead, CT-guided percutaneous drainage would be added to antibiotics.
- Free perforation with peritonitis (Hinchey III/IV) would require urgent laparotomy with resection and Hartmann's procedure.
- After recovery, colonoscopy at 6 weeks is recommended to exclude an underlying colonic carcinoma.
Create a decision tree for diverticulitis management based on Hinchey stage
Diverticulitis Decision Tree
Presentation · PPTX
What's inside (9 slides, dark navy + teal theme):
| Slide | Content |
|---|---|
| 1 - Title | Overview with color-coded stage legend (Stage 0 through IV) |
| 2 - Classification Table | Original Hinchey vs. Modified Wasvary (CT-based) side by side |
| 3 - Master Decision Tree | Full flowchart: CT assessment → Hinchey staging → Management → Outcomes |
| 4 - Stage 0 / Ia | Mild/uncomplicated: outpatient, ± oral antibiotics, ciprofloxacin + metronidazole regimen |
| 5 - Stage Ib | Confined pericolic abscess <5 cm: admit, IV antibiotics, monitor; pip-tazo regimen |
| 6 - Stage II | Large/pelvic abscess: CT-guided percutaneous drainage + IV antibiotics; surgical note |
| 7 - Stage III | Purulent peritonitis: resuscitate + emergency Hartmann's; LADIES/SCANDIV trial note; ~13% mortality |
| 8 - Stage IV | Fecal peritonitis: resuscitate + emergency Hartmann's; no primary anastomosis; ~43% mortality |
| 9 - Post-Acute | Colonoscopy timing (6-8 weeks), indications for elective surgery, contraindications, quick reference summary |