Definitions:

Diverticulosis: diverticula are present but the patient is asymptomatic

Diverticular disease: diverticula cause symptoms such as intermittent pain and/or tenderness without systemic upset

Diverticulitis: diverticula become inflamed and/or infected, typically causing constant severe lower abdominal pain, and commonly associated with fever, general malaise and occasionally rectal bleeding

'Uncomplicated' diverticulitis: localised diverticulitis not extending to the

peritoneum

'Complicated' diverticulitis: diverticulitis associated with complications eg abscess, peritonitis, fistula, obstruction or perforation

(Note: not all episodes of acute diverticulitis are caused by a bacterial infection with some episodes simply an inflammatory flare - more judicious use of antibiotics is now being advocated)

Questionnaire/history:

Constant abdominal pain?

Intensity (usually severe)?

Location?

- Starting in the hypogastrium before localising in the left lower quadrant?

(Note: in a minority of people and in people of Asian origin, pain may be localised in the right lower quadrant)

Fever?

Change in bowel habit?

Rectal bleeding (possible significant)?

Nausea?

Vomiting?

Dysuria?

Urinary frequency?

Examination:

Tenderness in the left lower quadrant?

Palpable abdominal mass?

Abdominal distension?

Investigations:

Full blood cell count?

CRP?

Management:

Urgent hospital admission if:

Suspected complication (eg rectal bleeding that may require urgent blood transfusion, bowel perforation, peritonitis or abscess)?

Symptoms which cannot be manage in primary care (eg severe abdominal pain)

Dehydrated or at risk of dehydration and is unable to take or tolerate oral fluids or antibiotics at home?

Admission considered if:

Consider admission if frail

Significant co-morbidities

Immunocompromised

Management in primary care if:

Suspected uncomplicated diverticulitis:

- Watchful waiting without antibiotics: if the person is systemically well, has no co-morbidities (eg immunocompromised, CKD, pregnant, long-term steroids) and there is no suspected infection

- Antibiotics if systemically unwell, immunocompromised or with significant comorbidity:

Co-amoxiclav 500/125 mg TID for 5 days (alternative is a combination of either cefalexin/trimethoprim/ciprofloxacin + metronidazole)

Advised:

Clear liquids only, with the gradual reintroduction of solid food if symptoms improve over the following 2–3 days

Paracetamol and/or antispasmodic eg hyoscine

To avoid NSAID/opioid analgesia if possible because of increased risk diverticular perforation

High-fibre diet for life (results may take weeks to achieve)

To consider a bulk-forming laxative

Review within 48 hours or sooner if symptoms worsen

Urgent hospital admission if symptoms persist or deteriorate despite management in primary care

To see a specialist in colorectal surgery if managed in primary care and frequent or severe recurrent episodes of acute diverticulitis

Resource(s):

NICE NG 147

CKS 2021