-Case-
A 55-year-old female who is an every-day smoker arrives at the emergency department clutching her left lower abdomen. She describes two days of progressively worsening pain along with nausea, a low-grade fever, and constipation. While she denies actively having blood in her stool, she mentions having these same symptoms a long time ago.
The possible causes for abdominal pain are never-ending. When you hear LLQ pain, what pathologies are unique to this area that you would want to evaluate for?
-Evaluation-
Diverticulitis often comes with telltale signs, but a thorough approach ensures an accurate diagnosis and appropriate treatment. In short, diverticulitis is the inflammation or infection of small outpouchings in the large intestinal wall. While the entire large bowel is at risk, it classically affects the sigmoid colon.
Pain in the left lower quadrant (LLQ) is often the hallmark symptom, reflecting involvement of the sigmoid colon. Alongside this, GI symptoms like nausea, vomiting, constipation, or diarrhea may all be present. A low-grade fever is also typical but higher temperatures can indicate more severe cases.
Now, it’s important to keep in mind who’s at risk. Your classic diverticulitis patient is over 50 years old, and their diet is low in fiber/high in processed foods. Obesity, smoking, and chronic NSAID use also increase the risk of diverticulitis. Lastly, diverticulosis or prior diverticulitis episodes dramatically increases risk as well.
When concerned about diverticulitis, a CT Abdomen/Pelvis with IV Contrast is the gold standard for identification. It’s useful in visualization of the sigmoid and evaluation for potential complications like abscesses or perforation. In patient with this pathology, you can also expect an elevated white count and inflammatory markers when evaluating labs.
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As alluded to earlier, some scary complications to watch for include perforation, abscess formation, fistulas, and obstruction. Often, sudden, sharp abdominal pain and signs of peritonitis require immediate intervention.
-Management-
Treatment largely depends on whether the case is classified as uncomplicated or complicated.
For uncomplicated diverticulitis, outpatient management is often appropriate. Antibiotic regimens like Metronidazole with Ciprofloxacin or Amoxicillin-Clavulanate are effective and do not require in-patient admission. Dietary adjustments with bowel rest to not overwhelm the GI system is also important. As you might expect, these patients need timely follow-up with GI and, in the meantime, can take acetaminophen (cautious use of NSAIDs) for their pain.
On the other hand, complicated diverticulitis is a different ballgame. These patients should be admitted to treat their severe pain, systemic infection, perforation, and/or inability to tolerate oral intake. Even before they get to the floor, broad-spectrum antibiotics (Zosyn or Ceftriaxone with Metronidazole) should be started. Additionally, our friends in surgery should hear about the case – with abscesses or perforation, diverticulitis patients often book themselves a trip to the OR.
-Fast Facts-
- The gears should start turning when you hear LLQ pain, fever, and GI symptoms in patients around or over 50 years old
- CT imaging is essential for diagnosing diverticulitis and identifying its complications
- Tailor treatment based on the severity of disease! Outpatient antibiotics for uncomplicated cases, inpatient care for complications or failed outpatient management
- Not a job for the ED, but a colonoscopy 6-8 weeks out is often helpful to rule out malignancy
Diverticulitis may be common, but its complications demand vigilance. Whether it’s a simple outpatient regimen or urgent surgical intervention, understanding the full spectrum of this condition ensures better outcomes for every patient.
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Cheers,
Tamir Zitelny, MD