How to manage a patient over 40 with known diverticulosis presenting with mild and intermittent left lower quadrant pain, without fever or signs of peritonitis?

Management of Mild Intermittent Left Lower Quadrant Pain in Known Diverticulosis Without Fever or Peritonitis

For a patient with known diverticulosis presenting with mild, intermittent left lower quadrant pain without fever or signs of peritonitis, imaging is not necessary and conservative outpatient management without antibiotics is appropriate. 1

Clinical Assessment

Your patient does not meet the classic triad of acute diverticulitis (left lower quadrant pain, fever, and leukocytosis), which is only present in 25% of diverticulitis cases anyway. 2 The absence of fever and peritoneal signs suggests this is either:

• Symptomatic diverticulosis (pain from the diverticula themselves without inflammation)
• Very mild uncomplicated diverticulitis that can be managed conservatively

The American College of Radiology guidelines explicitly state that imaging may not be necessary in patients with a history of diverticulitis who present with relatively mild clinical symptoms of recurrent disease. 1

When to Skip Imaging

You can safely avoid CT imaging in this patient because: 1, 2

• Pain is mild and intermittent (not progressively worsening)
• No fever present
• No signs of peritonitis (no guarding, rebound tenderness, or rigidity)
• Patient is hemodynamically stable
• Able to tolerate oral intake

Outpatient Management Strategy

Conservative management without antibiotics is the appropriate first-line approach: 2, 3

• Clear liquid diet initially, advancing as tolerated 3, 4
• Pain control with acetaminophen (avoid NSAIDs as they are a risk factor for diverticular complications) 3, 5
• Observation with close follow-up 2, 3
• No antibiotics are indicated for this presentation 2, 3

The World Journal of Emergency Surgery recommends conservative treatment without antibiotics for immunocompetent patients with uncomplicated diverticulitis, and your patient doesn't even clearly have acute diverticulitis. 2

When to Obtain Imaging

Order CT abdomen and pelvis with IV contrast if any of the following develop: 1, 2

• Fever develops
• Pain becomes severe or progressively worsens over several days
• Patient develops inability to tolerate oral intake
• Signs of peritonitis emerge (guarding, rebound tenderness, rigidity)
• Persistent symptoms beyond 2-3 days despite conservative management
• Vomiting or inability to pass gas/stool

CT with IV contrast has 98-99% sensitivity and 99-100% specificity for diagnosing diverticulitis and identifying complications. 2, 3

Red Flags Requiring Emergency Evaluation

Send the patient to the emergency department immediately if: 2

• Fever develops (temperature >100.4°F)
• Severe abdominal tenderness with guarding or rebound
• Inability to pass gas or stool with abdominal distension
• Vomiting
• Bloody stools
• Signs of shock (hypotension, tachycardia, altered mental status)

Critical Pitfall to Avoid

Do not prescribe antibiotics for this presentation. Multiple high-quality studies have shown that antibiotics do not accelerate recovery or prevent complications in uncomplicated diverticulitis, and your patient may not even have acute diverticulitis. 2, 3, 4 Antibiotics should be reserved for patients with systemic symptoms (persistent fever, increasing leukocytosis), age >80 years, pregnancy, immunocompromise, or significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes). 3

Follow-Up Instructions

Provide clear return precautions and schedule follow-up: 2

• Return immediately if fever, worsening pain, vomiting, or inability to eat/drink develops
• Follow up in 2-3 days if symptoms persist or worsen
• If symptoms resolve completely, routine follow-up as needed
• No colonoscopy is needed unless the patient is due for age-appropriate colon cancer screening or has never had adequate visualization of the colon 2