65 year old male. Comes with fever, left lower quadrant abdominal pain and mild signs of peritoneal inflamation (guarding and some rebound tenderness). He has a history of several years of constipation. He does not have gross hematochezia, but the miscroscopic analysis for blood in stools is positive. His CBC shows leukocytosis with PMN predominance, with no left shift.
So... up until now, the case doesnīt poses any trouble. A clear cut case of acute colonic diverticulitis. 8)
My question is... :?: What should be the next step in management of this patient?
Should I order Barium Enema? Sigmoidoscopy?
Do I confirm the diagnosis only clinically and treat him medically without further testing?
Do I confirm the diagnosis clinically and send him to the O.R.?
Some considerations... :idea: Directly from Harrisonīs
In a patient like this, colon cancer should be ruled out, even with a clear cut case like this. But...
Barium enema or Sigmoidoscopy can be hazardous, since contrast material or air under pressure mayu lead to rupture of an inflamed diverticulum and convert a walled-off inflamatory lesion to a free perforation.
So... what do we do next?? :?
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Guillermo Ballarino
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well sigmoidoscopy n BE r hazardous in acute phase so CT is the procedure of choice when in doubt. but it means u will do flex sigmoidoscopy later(after the acute attack) to rule out colon CA. For now do conservative managemnet with NPO n hydration. If pt has hx of 3 or more attacks of diverticulosis in past, u can do elective srugery but not in acute phase. If first time case, manage medically with colon CA follow up
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Would you add empyric antibiotics in the pre-op conservative management? letīs say Ampi+Gent, or Cefotaxime..
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Guillermo Ballarino
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