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.

Some useful reminders from Michael Sproat - GPwER at InHealth - see also further advice highlighted in green in sections below.

• Sometimes patients actually have IBS and it is erroneously called diverticular disease because after 30yrs of symptoms (IBS) they finally get a colonoscopy showing incidental findings (diverticulosis).
• Symptomatic diverticular disease is often erroneously called acute diverticulitis leading to lots of unnecessary antibiotics.
• Most individuals with large bowel diverticula experience no difficulties, with only 10–15% developing symptomatic diverticular disease (2).

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)

Key messages (from Michael Sproat):

• Make a clear diagnosis (diverticulosis/diverticular disease/acute diverticulitis).
• Keep an open mind and don’t miss cancer (if new presentation).
• Anyone with acute abdominal pain should be seen at the GP surgery face-to-face (avoid phone assessment) and have low threshold for same day hospital referral for consideration of CT abdomen if any concerning findings on examination.
• Consider checking FBC/CRP in general practice (for those not needing same day hospital assessment) to help differentiate flare-up of symptomatic diverticular disease from acute diverticulitis.
• Higher fibre diets are helpful (to avoid constipation), However, too much fibre is counterproductive as it may lead to more pain and bloating. The recommended approach is to increase fibre to an adequate amount when well, but not too much, and temporarily reduce if/when flare-up (hence guidance on low residue diets).
• If varying fibre is causing confusion, consider referral to dietician. Not needed in most cases, but may be appropriate especially if also IBS/vegetarian/diabetic etc. Referrals can be made to secondary care dieticians or PCN dieticians may also be able to advise. (Sirona dieticians will usually not accept referrals for this indication). 

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 - Faecal calprotectin check in older adults is rarely helpful (particularly if > 60yrs old) as much lower sensitivity and specificity in this group. Check calprotectin in younger patients as in some cases it is appropriate to exclude IBD, but in older patients FIT alone is likely to be sufficient.

• 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 antibiotics 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 are often not required 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. Consider deferred prescription or holding off antibiotics.

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- appropriate if there are concerns such as IBS overlap, patient anxiety, uncertainty that antibiotics are helpful/necessary- especially if these patients have never been ill enough to need acute hospital care.
• Secondary care referral via eRS  - if there are complications related to diverticular disease such as recurrent acute diverticulitis (as confirmed on CT/ recurrently elevated CRP/ hospital admissions). If advice on medical management is being requested then consider referral to gastroenterology.  If a patient is wishing to discuss elective sigmoid colectomy then refer to colorectal surgery.

Resources

References

(1) Diverticular disease | CKS

(2) Guidelines in Practice- Diverticular disease - Michael Sproat (2020)

Patient Information

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

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