Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Large Intestine
Question 2#

A 60-year-old male with no significant past medical history presents with sigmoid diverticulitis diagnosed by CT scan, which demonstrated microperforation and phlegmon. His vitals on presentation are within normal limits, laboratory test results are only significant for a leukocytosis, and abdominal examination demonstrates mild left lower quadrant abdominal tenderness without rebound or guarding. He is admitted to the hospital, kept NPO, and started on IV ciprofloxacin and metronidazole. On hospital day 4 he is transferred to the ICU with atrial fibrillation with rapid ventricular rate but remains normotensive. He is started on metoprolol with successful rate control. Laboratory test results demonstrate an acute kidney injury. His abdomen is distended and tender diffusely to palpation.

What is the next BEST step in his management?

A. Change antibiotics to meropenem
B. Noncontrast CT abdomen/pelvis
C. Start anticoagulation
D. Exploratory laparotomy and colectomy
E. Amiodarone bolus and infusion

Correct Answer is B

Comment:

Correct Answer: B

The patient has complicated diverticulitis as evidenced by microperforation and phlegmon. Patients who are hemodynamically stable are treated with parenteral antibiotics and NPO status. They are assessed daily for improvement in vital signs, abdominal examination, and diet toleration. Most improve within 2 to 3 days. This patient is showing signs of worsening abdominal pain, new onset atrial fibrillation, and end organ damage all concerning for sepsis. Failure to improve should prompt repeat imaging to evaluate for complications of diverticulitis such as abscess, frank perforation, or obstruction. As the patient has an acute kidney injury, contrast would place the patient at increased risk for worsening renal failure although it would surely increase the sensitivity of the CT scan. However, complications of diverticulitis such as frank perforation, free air and large abscesses, and distended bowel and obstruction will likely be evident on noncontrast CT scans. The patient with no past medical history and no recent hospital exposure is likely not at high risk for resistant organisms, such as extended spectrum beta lactamases. Thus, changing antibiotics to meropenem is less likely to improve the patient’s course. The patient has new onset atrial fibrillation, which began a few hours earlier and is responding well to rate control, which is the preferred strategy for initial management over rhythm control. His CHA2DS2 -VASc score is 0 and no valvular disease, lowering his risk for thromboembolism and not likely to require anticoagulation. The patient may require surgery based on the CT scan results; however, intra-abdominal abscesses related to diverticulitis respond well to percutaneous drainage and antibiotics.

References:

  1. Paterson DL, Bonomo RA. Extended-spectrum beta-lactamases: a clinical update. Clin Microbiol Rev. 2005;18:657.
  2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1.