Diverticular Disease - Draft

Overview

Diverticular disease refers to the presence of diverticula (small outpouchings of the colon wall), which may be asymptomatic or cause symptoms. It encompasses:

• Diverticulosis – asymptomatic diverticula

• Symptomatic diverticular disease – chronic abdominal symptoms with diverticula

• Acute diverticulitis – inflammation of diverticula

• Complicated diverticulitis – with perforation, abscess, fistula, or obstruction

Epidemiology

• The presence of diverticula is rare before the age of 40 years, and the risk increases with age.
• Risk is increased by a low fibre, obesity, and sedentary lifestyle.

Who to Refer

Patients with diverticular disease can usually be managed in primary care unless there are complications. Referral may be required in the following scenarios:

• Recurrent episodes of diverticulitis

• Persistent or worsening symptoms from diverticular disease

• Suspected complications (e.g., abscess, fistula, obstruction)

• Diagnostic uncertainty (consider IBD, cancer)

Red Flags

Acute Diverticulitis with complications - consider surgical admission for patients presenting with one or more of the following:

• Persistent fever >48 hours

• Peritonitis

• Recurrent vomiting

• Signs of sepsis

• Unable to tolerate fluids

• Suspected mass or abscess

• Significant rectal bleeding

Suspected malignancy

Consider investigation to exclude lower GI malignancy - see Lower GI - USC (2WW)

Before Referral

Diagnosis in Primary Care

 A thorough history and examination can help direct appropriate investigations

Investigations may include:

• Bloods: FBC, CRP, U&E, LFTs. Consider TTG, TFT, CA125 (if indicated in female patients with persistent abdo pain or bloating to help exclude ovarian cancer)

• Urinalysis - to exclude urine infection/bladder pathology.

• Stool test for M,C and S if infective diarrhoea suspected.

• FIT to exclude malignancy.

• Faecal calprotectin if IBD suspected

• Imaging - do not request plain abdominal x-rays. Consider CT abdo/pelvis if diagnostic uncertainty or  or to determine the extent and severity of disease, and exclude any complications (1).

• Endoscopy - consider lower GI endoscopy after resolution of acute complicated diverticulitis symptoms, to exclude alternative diagnoses such as inflammatory bowel disease, ischaemic colitis, or colorectal cancer (1). 

Management

Symptomatic Uncomplicated Diverticular Disease can be managed in primary care:

• High-fibre diet and fluids

• Antispasmodics (e.g., mebeverine) for abdominal cramps

• Simple analgesia (e.g. paracetamol. Avoid NSAIDs)

• Bulk-forming laxatives (e.g., ispaghula)

• Reassurance with safety-netting advice – a benign course is most likely

Acute Uncomplicated Diverticulitis (mild) with no red flags can often be managed in primary care:

• Advise clear fluids for 48 hours, then low-residue diet
• Do not give routine unless immunocompromised or systemic signs (1) - see below for further advice.
• Safety-netting and 48-hour review essential

Moderate-severe cases or complications (see red flags) - consider antibiotics or surgical admission.

Antibiotic use in diverticulitis

Antibiotics should not be used in patients with mild, uncomplicated diverticulitis which studies show do not have any benefit and may cause increase risk of side effects and antibiotic resistance.

Antibiotics (broad spectrum) should be considered if the person is systemically unwell or has significant co-morbidity but does not meet the criteria for admission to hospital. Patients prescribed antibiotics in the community should be given safety-netting advice and a review arranged within 48 hours or sooner if symptoms worsen. 

See BNSSG Formulary Primary Care Antimicrobial Guidelines for details on appropriate choice of antibiotic.

There is no role for antibiotics in preventing episodes of diverticulitis (1).

Referral

If admission is not indicated but there is still diagnostic uncertainty or uncontrolled symptoms despite optimal management in primary care consider the following options:

• Lower GI - USC (2WW) - if malignancy suspected.
• Gastroenterology and Colorectal Surgery Advice and Guidance
• Community Gastroenterology Clinic - InHealth
• Secondary care referral via eRS if there are complications related to diverticular disease - to gastroenterology or colorectal surgery as appropriate.

Resources

References

(1) Diverticular disease | CKS

Patient Information

• Diverticular disease and diverticulitis - NHS
• Diverticular Disease | Causes, Symptoms and Treatment - guts UK

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