How to manage a patient with known diverticulosis (diverticula in the colon), presenting with mild and intermittent left lower quadrant pain, without fever or signs of peritonitis, likely an older adult?

Management of Mild Intermittent Left Lower Quadrant Pain in Known Diverticulosis

Conservative outpatient management without antibiotics is appropriate for this patient, and imaging is not necessary unless symptoms worsen or new concerning features develop. 1

Initial Management Strategy

For patients with known diverticulosis presenting with mild, intermittent left lower quadrant pain without fever or signs of peritonitis, conservative management without imaging or antibiotics is the recommended approach. 1 The American College of Radiology explicitly states that imaging may not be necessary in patients with a history of diverticulitis who present with relatively mild clinical symptoms of recurrent disease. 1

Conservative Management Components

• Pain control with acetaminophen is the preferred analgesic, avoiding NSAIDs which are a risk factor for diverticular disease progression. 2
• Clear liquid diet advancement as tolerated, progressing to regular diet as symptoms improve. 1
• Outpatient observation is appropriate when the patient can tolerate oral intake, has no fever, and demonstrates no signs of peritonitis. 1

When to Escalate Care

CT abdomen and pelvis with IV contrast should be ordered if any of the following develop: 1

• Fever (temperature elevation suggesting infection)
• Severe or progressively worsening pain
• Inability to tolerate oral intake
• Signs of peritonitis (guarding, rebound tenderness, rigidity)
• Persistent symptoms beyond 2-3 days despite conservative management

Antibiotic Considerations

Antibiotics are NOT indicated for this patient based on current evidence. 1, 2 The World Journal of Emergency Surgery recommends conservative management without antibiotics for immunocompetent patients with uncomplicated diverticulitis. 1

Exceptions Requiring Antibiotics

Antibiotics should be reserved for specific high-risk situations: 2

• Persistent fever or chills
• Increasing leukocytosis
• Age older than 80 years
• Pregnancy
• Immunocompromised state (chemotherapy, high-dose steroids, organ transplant)
• Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes)

If antibiotics become necessary, first-line oral therapy includes amoxicillin/clavulanic acid or cefalexin with metronidazole. 2

Critical Pitfalls to Avoid

• Do not routinely order CT imaging for mild symptoms in known diverticulosis, as this leads to unnecessary radiation exposure and healthcare costs without changing management. 1
• Do not prescribe antibiotics reflexively, as uncomplicated diverticulitis in immunocompetent patients does not benefit from antibiotic therapy and contributes to antimicrobial resistance. 1, 2
• Do not use NSAIDs for pain control, as these medications are risk factors for diverticular disease and may worsen outcomes. 2, 3

Patient Education and Follow-up

Advise the patient to return immediately if red flag symptoms develop: 1

• Fever
• Inability to pass gas or stool
• Severe abdominal tenderness
• Vomiting
• Bloody stools
• Progressively worsening pain

Long-term Prevention Strategies

Recommend lifestyle modifications to prevent recurrent episodes: 2, 4

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Limit red meat and sweets
• Maintain BMI 18-25 kg/m²
• Regular physical activity
• Smoking cessation
• Avoid long-term NSAID use

Colonoscopy Considerations

Routine colonoscopy after this episode is NOT warranted unless the patient has not had age-appropriate colon cancer screening or develops complicated diverticulitis. 1 Colonoscopy should be considered if abscess, perforation, fistula, or diagnostic uncertainty develops. 1