What is the best course of action for a patient with a history of diverticulitis and gastroparesis, presenting with stomach pain, distension, and potential bleeding, who is refusing to go to the emergency room but has upcoming endocrinology and hepatology/GI appointments?

Immediate Management Strategy for High-Risk Patient Refusing Emergency Care

This patient requires urgent outpatient escalation and close monitoring given her history of diverticulitis with prior perforation and abscess, current abdominal distension with right-sided pain, and potential bleeding—she should be contacted immediately before her scheduled GI/hepatology appointments to arrange expedited evaluation within 24-48 hours rather than waiting weeks, and if symptoms worsen (increased pain, fever, hemodynamic instability, or inability to tolerate oral intake), emergency services must be activated regardless of her preferences. 1

Risk Stratification and Urgency Assessment

This patient presents with multiple concerning features that elevate her risk profile:

• History of complicated diverticulitis (perforation and abscess with bleeding) places her at significantly higher risk for recurrent complications 1
• Current symptoms of abdominal distension and right-sided pain in the context of known diverticulosis and gastroparesis require urgent evaluation to exclude bowel obstruction, recurrent diverticulitis, or perforation 1
• Potential ongoing bleeding combined with iron deficiency anemia suggests active or recent gastrointestinal blood loss requiring investigation 1
• Gastroparesis with distension increases risk of aspiration and can mask or complicate other acute abdominal processes 2

Immediate Action Steps Before Scheduled Appointments

Contact Patient's Scheduled Providers Urgently

• Call the hepatology/GI office immediately to explain the clinical situation and request expedited appointment (within 24-48 hours rather than waiting for the scheduled date) 1
• Emphasize the combination of prior complicated diverticulitis, current abdominal distension with pain, and patient's refusal of emergency care 1
• Request that the GI team consider urgent imaging (CT abdomen/pelvis with IV and oral contrast) prior to or at the time of the appointment 1

Optimize Pain Management While Avoiding High-Risk Medications

• Discontinue naproxen immediately as NSAIDs significantly increase risk of diverticulitis complications and perforation 3, 4
• Switch to acetaminophen as the primary analgesic for her chronic pain, as this is the recommended first-line agent for patients with diverticular disease 4
• Avoid opioid escalation as opioids are associated with increased risk of diverticulitis and perforation 3
• Consider low-dose tricyclic antidepressant (e.g., amitriptyline 10-25 mg at bedtime) for chronic visceral pain if acetaminophen is insufficient 1, 4

Establish Clear Warning Signs for Emergency Care

Despite her reluctance, establish specific criteria that mandate emergency evaluation:

• Fever >38.5°C (101.3°F) suggests possible abscess or perforation requiring urgent intervention 1
• Worsening abdominal pain or new peritoneal signs (rebound tenderness, rigidity) indicate potential perforation 1
• Inability to tolerate oral intake or persistent vomiting may indicate bowel obstruction requiring urgent decompression 1
• Hemodynamic instability (lightheadedness, syncope, tachycardia) suggests significant bleeding requiring transfusion 1
• Passage of bright red blood per rectum or melena warrants urgent evaluation to exclude active bleeding 1

Diagnostic Workup at Upcoming Appointments

Essential Imaging Studies

• CT abdomen/pelvis with IV and oral contrast is the gold standard for evaluating suspected diverticulitis complications and should be obtained urgently 1
• CT can identify abscess formation, perforation with free air, bowel obstruction, or alternative diagnoses 1
• If CT shows abscess >4 cm, percutaneous drainage may be indicated rather than surgery 1

Laboratory Monitoring

• C-reactive protein (CRP) is the most useful biomarker for predicting severity of diverticulitis; CRP >170 mg/L indicates high risk for complicated disease requiring intervention 1
• Complete blood count to assess for leukocytosis (suggesting active infection) and degree of anemia (indicating ongoing or recent bleeding) 1
• Hemoglobin trend should be monitored given her iron deficiency anemia and history of diverticular bleeding 1

Endoscopic Evaluation Timing

• Colonoscopy should be delayed 6-8 weeks after resolution of acute diverticulitis symptoms to avoid perforation risk 1
• However, given her history of complicated diverticulitis with perforation, colonoscopy is indicated once acute symptoms resolve to exclude malignancy (1.9% prevalence of colon cancer after diverticulitis, 7.9% in complicated cases) 1
• If alarm symptoms persist (ongoing bleeding, weight loss, change in stool caliber), earlier endoscopy may be warranted 1

Management of Gastroparesis Contributing to Symptoms

Her gastroparesis likely contributes to abdominal distension and pain:

• Continue metoclopramide for gastroparesis but monitor for extrapyramidal side effects given her schizoaffective disorder 2
• Maintain clear liquid diet during acute symptoms to minimize gastric residual and mechanical irritation 1, 2
• Advance diet gradually as symptoms improve, focusing on small, frequent meals 1, 2
• Consider gastric emptying study if symptoms persist despite medical management 2

Addressing Medication Non-Adherence and Safety

Given her poor medication compliance and altered mental status:

• Continue twice-weekly medication monitoring as currently implemented 1
• Simplify pain regimen to acetaminophen only (discontinue naproxen) to reduce confusion and risk 4
• Ensure brother and homemaker understand warning signs for emergency care, as they may need to advocate for her 1
• Document patient's refusal of emergency care while continuing to educate about risks 1

Dietary Modifications for Diverticular Disease

Once acute symptoms resolve:

• High-fiber diet (>22 g/day) from fruits, vegetables, whole grains, and legumes reduces risk of recurrent diverticulitis 3, 5
• Avoid restrictive diets—nuts, popcorn, and seeds do NOT need to be avoided and may actually be protective due to fiber content 3, 5
• Limit red meat and sweets as part of prudent dietary pattern 3, 5

Common Pitfalls to Avoid

• Do not delay imaging while waiting for scheduled appointments if symptoms worsen—this patient's history of perforation makes her high-risk 1
• Do not continue NSAIDs (naproxen) in patients with diverticular disease due to significantly increased perforation risk 3, 4
• Do not assume all abdominal pain is from diverticulitis—gastroparesis, bowel obstruction, ischemia, and malignancy must be excluded 1
• Do not perform colonoscopy during acute symptoms as this increases perforation risk; wait 6-8 weeks after symptom resolution 1
• Do not routinely prescribe antibiotics for uncomplicated diverticulitis in immunocompetent patients, but this patient's complicated history and immunosuppression from diabetes may warrant selective use if acute diverticulitis is confirmed 1

Contingency Planning

If the patient develops any warning signs before her scheduled appointments:

• Activate emergency services immediately and inform them of her history of diverticular perforation and current symptoms 1
• Contact her brother (who is bilingual) to help communicate the urgency and overcome language barriers 1
• Provide written instructions in Spanish outlining specific symptoms requiring emergency care 1