What is the evaluation and treatment for intermittent sharp pressure pain on the left side of the colon?

Evaluation and Treatment for Left-Sided Colon Pressure Pain

CT imaging with contrast is the recommended first-line diagnostic test for patients with intermittent sharp pressure pain on the left side of the colon, as it provides the highest diagnostic accuracy for identifying common causes including diverticulitis, colitis, and other bowel pathologies. 1

Initial Diagnostic Approach

• CT abdomen and pelvis with IV contrast is the most appropriate initial investigation for chronic left-sided colon pain, with high sensitivity for detecting bowel wall pathology, pericolic abnormalities, and fluid collections 2, 1
• CT imaging can effectively differentiate between common causes of left-sided pain including diverticulitis (most common), colitis, inflammatory bowel disease, epiploic appendagitis, and bowel obstruction 1
• If IV contrast is contraindicated, CT abdomen and pelvis without contrast may be appropriate with similar diagnostic accuracy 1
• Ultrasound may be considered as an alternative to reduce radiation exposure in selected patients, particularly when directed at the area of maximal pain 1

Diagnostic Considerations for Left-Sided Colon Pain

• Diverticulitis is the most common cause of left lower quadrant pain in adults, particularly in patients over 40 years of age 2
• Key diagnostic features of diverticulitis on CT include bowel wall thickening, pericolic fat stranding, and presence of diverticula 2
• CT can also identify complications of diverticulitis such as abscess, phlegmon, fistula, obstruction, or perforation 2
• Other potential causes to consider include:
  • Irritable bowel syndrome (IBS) - typically presents with chronic, recurrent abdominal pain associated with changes in bowel habits 3, 4
  • Ischemic bowel disease - can present with acute or chronic abdominal pain 5
  • Epiploic appendagitis - self-limited inflammation of epiploic appendages 6
  • Colorectal cancer - may rarely present with symptoms similar to diverticulitis 2

Management Approach

For Uncomplicated Diverticulitis

• Most patients with acute uncomplicated left-sided colonic diverticulitis can be managed in an outpatient setting 2
• Select immunocompetent patients with uncomplicated diverticulitis can be initially managed without antibiotics through observation with supportive care (bowel rest and hydration) 2
• Predictors of progression to complicated disease include symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels (>140 mg/L), and CT findings of pericolic extraluminal air or fluid collection 2

For Complicated Diverticulitis

• Patients with complicated diverticulitis (with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) require more aggressive management 2
• These patients should be referred for colonoscopy after resolution of the acute episode if they have not had a recent colonoscopy, to rule out colorectal cancer 2
• Elective surgery may be considered for patients with persistent or frequently recurring uncomplicated diverticulitis or complicated diverticulitis 2
• The decision for surgery should be personalized based on potential benefits, harms, costs, and patient preferences 2

Follow-up Recommendations

• Patients with complicated diverticulitis should be referred for colonoscopy after resolution of symptoms if they have not had a recent colonoscopy 2
• Mesalamine is not recommended for prevention of recurrent diverticulitis 2
• Patients with persistent symptoms despite appropriate treatment should be evaluated for other potential causes, including colorectal cancer, inflammatory bowel disease, or irritable bowel syndrome 2, 4

Clinical Pitfalls and Caveats

• Perforated colon cancer can mimic both the clinical and radiographic findings of diverticulitis; CT findings that suggest colon cancer include pericolonic lymphadenopathy (>1 cm in short axis) 2
• Consider cumulative radiation exposure when ordering multiple CT scans, especially in younger patients 1
• Psychosocial evaluation should be considered in patients with chronic pain, as psychological factors can influence pain perception and treatment outcomes 1
• Left-sided abdominal pain can be referred from other anatomical locations, so a thorough evaluation is necessary to avoid misdiagnosis 3, 6