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A 68-year-old man presents with 3 days of left lower quadrant pain, fever (38.5°C), and constipation. On examination: temperature 38.5°C, HR 96, BP 130/80. Abdomen: LLQ tenderness and guarding, no rigidity. Bloods: WBC 14.5 x 10^9/L, CRP 89 mg/L.
Questions
a) What is the most likely diagnosis and gold standard investigation? (2 marks)
Acute uncomplicated diverticulitis. Gold standard: CT abdomen/pelvis with IV contrast — grades severity, identifies complications (abscess, perforation, fistula). Avoid colonoscopy during acute episode (risk of perforation through inflamed diverticular wall).
b) Describe the initial management. (3 marks)
- Oral antibiotics: amoxicillin-clavulanate 625 mg TDS (or ciprofloxacin 500 mg BD + metronidazole 400 mg TDS) for 7-10 days
- Clear fluids for 24-48 hours, then low-residue diet
- Paracetamol for analgesia (avoid NSAIDs — perforation risk; avoid opioids — pseudo-obstruction)
- Outpatient management (stable patient, no peritonitis, no systemic sepsis)
- Advice to return if worsening pain, fever, or signs of peritonitis
c) The patient represents 5 days later with generalised abdominal pain, rigidity, and fever of 39°C. Erect CXR shows free air under the right hemidiaphragm. What complication has occurred and what is the management? (3 marks)
Perforated diverticulitis with peritonitis (likely Hinchey III or IV).
Management:
- Emergency surgery — midline laparotomy
- Resuscitation: IV fluids, broad-spectrum IV antibiotics (co-amoxiclav + metronidazole), catheterise, crossmatch
- Hartmann's procedure if faecal peritonitis (Hinchey IV): sigmoid resection + end colostomy + closed rectal stump
- Primary anastomosis with defunctioning ileostomy if purulent peritonitis only (Hinchey III) and patient stable
- HDU/ITU post-operatively
d) After recovery, what follow-up is essential? (2 marks)
Colonoscopy at 6-8 weeks after complete resolution to exclude underlying colorectal cancer (which can mimic diverticulitis). If recurrent episodes (2+), consider elective laparoscopic sigmoid resection.