What is the treatment for a patient with left-sided abdominal pain?

From the Guidelines

The most appropriate initial treatment for a patient with left-sided abdominal pain suspected to be due to acute uncomplicated left-sided colonic diverticulitis is outpatient management without antibiotics, unless there are signs of complications or systemic inflammatory response, as suggested by the American College of Physicians guideline 1.

When diagnosing acute left-sided colonic diverticulitis, a detailed history, physical examination, and laboratory findings are the first steps, and abdominal CT imaging can be used when there is diagnostic uncertainty, as it has high sensitivity and specificity for diagnosing diverticulitis 1.

For patients with acute uncomplicated left-sided colonic diverticulitis, outpatient management is recommended, as it is associated with lower risks of potential harms related to hospitalization and lower costs, without differences in critical outcomes such as elective surgery or long-term diverticulitis recurrence 1.

Initial management without antibiotics can be considered for select patients with acute uncomplicated left-sided colonic diverticulitis, as low-certainty evidence shows no differences in diverticulitis-related complications or quality of life between those receiving and those not receiving antibiotics, and it may reduce the risk of antibiotic resistance and associated costs 1.

Some key considerations for outpatient management without antibiotics include:

• The patient should be immunocompetent and have no evidence of systemic inflammatory response or immunosuppression.
• The patient should be able to continue treatment at home under medical supervision with adequate family and social support and follow-up.
• Predictors of progression to complicated disease, such as symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels, or CT findings of pericolic extraluminal air or fluid collection, should be taken into account.

It is essential to note that these recommendations do not apply to patients with suspected complicated diverticulitis, recent antibiotic use, concomitant unstable comorbid conditions, immunosuppression, or signs of sepsis, and that clinicians should err on the side of imaging and hospitalization for patients with predictors of progression to complicated disease or signs of complications.

In contrast to the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1, the American College of Physicians guideline 1 provides more specific and detailed recommendations for the management of acute uncomplicated left-sided colonic diverticulitis, including the use of outpatient management without antibiotics for select patients.

Overall, the treatment approach for left-sided abdominal pain should be individualized based on the patient's specific clinical presentation, medical history, and preferences, and should prioritize minimizing morbidity, mortality, and improving quality of life.

From the Research

Diagnosis and Treatment of Left-Sided Abdominal Pain

The treatment for a patient with left-sided abdominal pain depends on the underlying cause of the pain. Some possible causes of left-sided abdominal pain include diverticulitis, colitis, and urolithiasis.

Diverticulitis Treatment

• For uncomplicated diverticulitis, outpatient treatment with oral antibiotics may be effective 2.
• However, the use of antibiotics for uncomplicated diverticulitis is uncertain, and some studies suggest that they may not be necessary 3.
• A study comparing metronidazole-with-fluoroquinolone to amoxicillin-clavulanate for outpatient diverticulitis found no differences in admission risk, urgent surgery risk, or elective surgery risk between the two groups 4.
• For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, may be indicated, while surgical intervention may be necessary for peritonitis or failure of non-operative management 5.

Diagnostic Imaging

• Computed tomography (CT) is the preferred imaging modality for evaluating left lower quadrant abdominal pain, including diverticulitis, colitis, and urolithiasis 6.
• CT scans can help diagnose the underlying cause of the pain and guide treatment decisions.

Treatment Considerations

• The management of diverticulitis depends on the classification of the disease as complicated or uncomplicated, based on CT scan, severity of symptoms, and patient history 5.
• Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis, while hospital admission may be necessary for patients with complicated diverticulitis or severe symptoms.
• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 5.