STORY
47 year old with no significant history apart from diverticulitis, presents with left flank pain similar to prior diverticular disease. Pain is of varying intensity. No hematuria. No dysuria. No fevers or chills. No vomiting or diarrhea.
In the ED he is comfortable and afebrile with normal vital signs.
ULTRASOUND
Point of care ultrasound at the point of maximal tenderness over the patient’s left upper quadrant/flank was performed with the large curvilinear transducer. The patient had tenderness to sonopalpation, with bowel wall edema greater than 0.5cm, enhancement of the pericolonic fat. No diverticula were noted. There was no surrounding fluid or hypoechoic collection to suggest abscess or perforation. These findings were suggestive of colitis.
Complicated diverticulitis would be indicated by: intraperitoneal free fluid, 2 or more areas of bowel wall edema in different abdominal quadrants, free air, presence of an abscess, or dilated loops of bowel greater than 2.5cm.
The (95% CI) test characteristics of POCUS in identifying diverticulitis, complicated diverticulitis, and colitis, as compared with CT findings, have been found to be:
- Sensitivity 0.92 (0.88–0.96)
- Specificity 0.97 (0.94–0.99)
- LR+ 30.67
- LR- 0.08
LABS
Labs are reassuring including WBC 8000 with no shift and a normal urinalysis.
MEDICATIONS
- 1000 cc of Normal Saline
- Oral and Intravenous Iohexol for CT
- Did not require analgesia in the ED
COMPUTED TOMOGRAPHY
A representative image below of his CT scan, shows: “mild/moderate wall thickening of the descending colon with mild surrounding inflammatory changes. No extraluminal air or rim-enhancing collection noted. This was interpreted as “descending colon colitis/diverticulitis without evidence of perforation or abscess.”
MANAGEMENT
Our past paradigm of outpatient diverticulitis management centered around antibiotic administration. In reviewing treatment for diverticulitis, the Cochrane Library Systematic Review reminds us that, “antibiotics can cause serious adverse effects, including life-threatening allergic reactions or super-infections of the intestine. Growing antibiotic resistance is an increasing problem rendering some infections impossible to treat with possible fatal outcomes. Therefore, strong arguments in favour of limiting the current use of antibiotics exist. Only three randomised controlled trials on the need of antibiotics are currently available and more are needed in order to obtain strong and reliable evidence. “ (Cochrane 2022)
Incorporating recent evidence into their guidelines, the American Gastroenterological Association (AGA 2015) recommends that “antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. (qualifying that this is a conditional recommendation, with low quality of evidence).
Acknowledging that more evidence would be valuable, the 2022 Cochrane review, nonethless clarifies as follows:
the newest evidence shows that the use of antibiotics for the treatment of uncomplicated acute diverticulitis is not superior to treatments that do not include antibiotics.”