What is the next step in managing abdominal pain in a patient with diverticulosis (inflammation of diverticula) without diverticulitis (inflammation of diverticula)?

Management of Abdominal Pain in a Patient with Diverticulosis Without Diverticulitis

For patients with diverticulosis experiencing abdominal pain without evidence of diverticulitis, the next step should be diagnostic imaging with CT scan and laboratory testing to rule out ongoing inflammation, followed by colonoscopy after 6-8 weeks if not recently performed. 1

Initial Evaluation

Diagnostic Imaging

• CT scan with IV contrast is the preferred initial imaging modality 1
  • Helps differentiate between uncomplicated diverticulosis and early diverticulitis
  • Can identify other potential causes of abdominal pain

Laboratory Testing

• Complete blood count to check for leukocytosis
• C-reactive protein (CRP) levels
• Procalcitonin in select cases 1

Management Algorithm

If Imaging and Labs Are Normal (No Active Inflammation)

1. Consider visceral hypersensitivity as the cause of pain 1

   • This is common in patients with history of diverticulosis, affecting approximately 45% of patients 1
   • Treatment options:
     • Low to modest dose tricyclic antidepressant for pain management 1
     • Gradually introduce high-fiber diet (25-35g daily) 2

2. Dietary modifications:

   • Start with a clear liquid diet during acute pain episodes 1
   • Gradually advance to a high-fiber diet as symptoms improve 1, 2
   • Consider fiber supplementation (psyllium) starting with low doses to avoid bloating 2
   • Contrary to older recommendations, nuts, seeds, corn, and popcorn do not need to be avoided 2, 3

3. Schedule colonoscopy if not performed within the past year 1

   • Delay colonoscopy for 6-8 weeks after acute symptoms resolve 1
   • Earlier colonoscopy if alarm symptoms are present (change in stool caliber, iron deficiency anemia, blood in stool, weight loss) 1

If Imaging Shows Mild Inflammation or Unclear Findings

1. Consider selective antibiotic use 1, 4
   • Antibiotics are not routinely needed for mild uncomplicated cases in immunocompetent patients 1, 4
   • Reserve antibiotics for patients with:
     • Comorbidities or frailty
     • Refractory symptoms or vomiting
     • CRP >140 mg/L or WBC >15 × 10^9 cells/L 1
     • Immunocompromised status 4
   • First-line oral antibiotics: amoxicillin/clavulanic acid or cefalexin with metronidazole 4

Lifestyle Modifications for Long-term Management

• Regular vigorous exercise 2
• Maintain normal BMI 2
• Avoid smoking 2
• Limit use of NSAIDs and opioid analgesics 2, 4

Common Pitfalls and Caveats

1. Misdiagnosis risk: Colon cancer can be misdiagnosed as diverticulitis. The pooled prevalence of colon cancer is 1.9% among patients with diverticulitis, with higher risk (7.9%) in complicated cases 1.

2. Overuse of antibiotics: Antibiotics should be used selectively rather than routinely in uncomplicated cases 1, 4.

3. Inadequate follow-up: Failure to schedule colonoscopy after a first episode of diverticular disease can miss underlying malignancy 1.

4. Outdated dietary restrictions: Advising patients to avoid nuts and seeds is not supported by evidence and may unnecessarily restrict diet 2, 3.

5. Sudden fiber introduction: Rapidly increasing fiber intake can worsen symptoms; gradual introduction is recommended 2.