In an elderly man with known diverticulosis presenting with mild intermittent left lower quadrant pain, no fever, normal white blood cell count, and no peritoneal signs, what is the most appropriate initial management?

Initial Management: Increase Fiber and Fluid Intake

In this elderly man with known diverticulosis presenting with mild intermittent left lower quadrant pain, normal vital signs, no fever, normal WBC count, and no peritoneal signs, the most appropriate initial management is to increase fiber and fluid intake (Option C).

Rationale for Conservative Management Without Imaging or Antibiotics

This clinical presentation is most consistent with symptomatic uncomplicated diverticular disease rather than acute diverticulitis, making conservative dietary management the appropriate first-line approach.

Why CT Imaging Is Not Immediately Indicated

• While CT abdomen/pelvis with IV contrast is the gold standard for diagnosing acute diverticulitis with 98-99% sensitivity and specificity, it is reserved for patients with clinical features suggesting acute diverticulitis 1, 2.
• The WSES guidelines emphasize CT imaging in elderly patients when there is suspicion of acute diverticulitis to distinguish complicated from uncomplicated disease and rule out alternative diagnoses 1.
• This patient's presentation—mild, intermittent pain without fever, leukocytosis, or peritoneal signs—does not meet criteria for acute diverticulitis requiring immediate imaging 3, 1.
• CT should be obtained if symptoms worsen, become persistent beyond 2-3 days, or if fever (>38°C) or peritoneal signs develop 4.

Why Antibiotics Are Not Indicated

• The WSES 2022 guidelines explicitly state that antibiotic therapy should be avoided in immunocompetent elderly patients with uncomplicated left colonic diverticulitis (WSES stage 0) without sepsis-related organ failures 3.
• Antibiotics are reserved for patients with systemic signs including persistent fever, chills, increasing leukocytosis, age >80 years, immunocompromise, pregnancy, or serious comorbidities such as cirrhosis, chronic kidney disease, heart failure, or poorly controlled diabetes 4, 2.
• This patient has none of these high-risk features, making antibiotics unnecessary and potentially harmful through unnecessary antimicrobial exposure 1.
• The AVOD and DIABOLO trials demonstrated that antibiotic treatment in uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrences 3.

Why Laparotomy Is Contraindicated

• Laparotomy is indicated only for generalized peritonitis with organ dysfunction (WSES stage 3-4), free intraperitoneal air with diffuse peritonitis, or failure of medical management in complicated diverticulitis 1, 4.
• This patient has no peritoneal signs, making surgical intervention completely inappropriate 3.

Appropriate Initial Management Strategy

Dietary Modification

• High-fiber diet (25-30 grams daily) is the cornerstone of management for symptomatic diverticular disease 5, 6.
• Increased fluid intake (at least 8 glasses of water daily) helps soften stool and reduce intraluminal pressure 6.
• The myth of avoiding nuts, corn, popcorn, and seeds has been debunked; these foods do not increase diverticulitis risk 6.
• Dietary recommendations mirror overall healthy lifestyle guidelines: high fiber with focus on whole grains, fruits, and vegetables 6.

Pain Management

• Acetaminophen is appropriate for mild pain control 2.
• Avoid NSAIDs, as they are a risk factor for diverticular disease progression 6.

Red-Flag Symptoms Requiring Escalation of Care

The patient should be instructed to seek immediate medical attention if any of the following develop:

• Temperature exceeding 38°C 4.
• Development of peritoneal signs—guarding, rebound tenderness, or rigidity 4.
• Persistent or worsening pain beyond 2-3 days despite conservative management 4.
• Inability to tolerate oral intake, nausea, or vomiting 2.

Follow-Up Considerations

• If symptoms persist or worsen despite 2-3 days of conservative management, obtain CT abdomen/pelvis with IV contrast to reassess for complications or alternative pathology 4.
• Consider colonoscopy 6-8 weeks after symptom resolution if the patient is >50 years without recent colonoscopy, as colorectal cancer can present with similar symptoms 3, 6.

Common Pitfalls to Avoid

• Do not empirically treat with antibiotics without confirming acute diverticulitis, as this leads to unnecessary antimicrobial exposure without proven benefit 1.
• Do not obtain CT imaging for every episode of mild abdominal pain in patients with known diverticulosis unless clinical features suggest acute inflammation 3, 1.
• Do not recommend low-fiber or "diverticulitis diet" during asymptomatic periods; high fiber is protective 6.