What is the next step in managing a 48-year-old male (YOM) with uncomplicated sigmoid diverticulitis who has persistent severe left lower quadrant (LLQ) abdominal pain despite being on ciprofloxacin (Cipro) and metronidazole?

Management of Persistent Pain in Uncomplicated Diverticulitis Despite Antibiotic Therapy

This patient requires repeat CT imaging immediately to evaluate for progression to complicated diverticulitis, as persistent severe pain (7/10) after 3 days of appropriate antibiotics is a red flag for treatment failure or missed complications. 1, 2

Immediate Assessment and Imaging

Repeat CT scan is mandatory when clinical improvement does not occur within 2-3 days of antibiotic therapy, as this may reveal previously undetected abscess, phlegmon, or fistula formation that requires different management. 3 The key clinical indicators that should trigger repeat imaging include:

• Pain score ≥8/10 at presentation or persistent pain ≥7/10 after 48-72 hours of treatment (this patient meets criteria with 7/10 pain at day 3) 1, 2
• Failure to tolerate oral intake
• Persistent fever >100.4°F
• Worsening or static leukocytosis 2

Critical Risk Stratification

This 48-year-old patient has two significant risk factors for progression to complicated diverticulitis:

1. Age <50 years - younger patients have increased risk for complicated or recurrent disease 1
2. High pain score - pain ≥8/10 at presentation or persistent severe pain predicts worse outcomes 1, 2

Pain Management Strategy

The patient is not on any pain medications, which is a critical oversight. For observational treatment of diverticulitis, patients should have:

• Pain score below 4/10 using acetaminophen for pain control 1
• This patient's 7/10 pain indicates inadequate symptom control and potential treatment failure

Initiate acetaminophen immediately (the only recommended analgesic for diverticulitis) while avoiding NSAIDs and opioids, which increase risk of complications. 2, 4

Decision Algorithm Based on Repeat CT Findings

If CT Shows Uncomplicated Disease (No Abscess/Perforation):

Consider admission for IV antibiotics and closer monitoring given:

• Persistent severe pain despite 3 days of oral therapy
• Age <50 years (high-risk group)
• Failure to meet outpatient management criteria (pain >4/10) 1, 2

Switch to IV antibiotics: ceftriaxone plus metronidazole OR piperacillin-tazobactam 2, 4

However, avoid ceftriaxone for >4 days as this significantly increases intra-abdominal Enterococcus faecium colonization (37% vs 2.7% with immediate operation), which complicates subsequent management if surgery becomes necessary. 5

If CT Shows Complicated Disease:

Small abscess (<4-5 cm): Continue antibiotics alone for total 7 days 2, 6

Large abscess (≥4-5 cm): Percutaneous drainage plus antibiotics for 4 days 1, 2, 6

Generalized peritonitis: Emergent surgical consultation for laparotomy and colonic resection 4

Common Pitfalls in This Case

The initial management missed several key elements:

1. No pain medication prescribed - acetaminophen should have been started immediately to target pain <4/10 1
2. No clear follow-up plan - re-evaluation should occur within 7 days, or earlier if deterioration occurs 1, 2
3. Possible inappropriate antibiotic use - if this patient had no systemic symptoms, immunocompromise, or high-risk features initially, antibiotics may not have been indicated at all 1, 2

Surgical Consultation Considerations

Obtain surgical consultation now if:

• Repeat CT shows perforation, large abscess not amenable to drainage, or peritonitis 2, 6
• Clinical deterioration occurs (sepsis, inability to tolerate oral intake, worsening pain) 1, 4
• Patient is immunocompromised (requires lower threshold for intervention) 2, 4

Note: Elective sigmoid resection after this episode may be considered given the patient's young age (<50 years), as this population has higher recurrence rates and may benefit from earlier definitive surgical management. 7