Diverticular Disease

 

Diverticular disease is a condition where diverticula, sac-like protrusions of mucosa through the muscular wall of the colon, cause symptoms such as intermittent lower abdominal pain, without inflammation and infection.  Where diverticula are present without symptoms it is known as diverticulosis.  Where diverticula become inflamed and infected the condition is called diverticulitis, and typically causes severe lower abdominal pain, fever, general malaise, and occasionally rectal bleeding. The exact cause for the development of diverticular disease and diverticulitis is not known, but risk factors such as genetics, obesity, smoking, drugs, and a low fibre diet may be involved.  About 75% of people with diverticula have asymptomatic diverticulosis, and about 25% will develop symptomatic diverticular disease.  The presence of diverticula is rare before the age of 40 years, and the risk increases with age.  About 5% of people with diverticula will develop complicated disease

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Diagnosis

Consider an alternative cause for symptoms before making a working diagnosis of diverticular disease or diverticulitis

  1. Diverticulosis is asymptomatic and in most people remains undiagnosed
    1. It may present with a large, painless rectal bleed, or be found incidentally during investigation for other symptoms
  2. Suspect diverticular disease if a person presents with:
    1. Intermittent abdominal pain in the left lower quadrant. Pain may be triggered by eating and may be relieved by the passage of stool or flatus
    2. Constipationdiarrhoea, or occasional large rectal bleeds
    3. Bloating and the passage of mucus rectally
    4. Tenderness in the left lower quadrant on abdominal examination
  3. Suspect diverticulitis if a person presents with:
    1. Constant abdominal pain, usually severe and starting in the hypogastrium before localizing in the left lower quadrant, with fever
      1. NOTE In a minority of people and in people of Asian origin, pain may be localized in the right lower quadrant
    2. Change in bowel habit, and possible significant rectal bleeding
    3. Possible nausea, vomiting, dysuria, and urinary frequency
    4. A previous history of diverticulosis or diverticulitis
    5. Tenderness in the left lower quadrant, palpable abdominal mass or distention on abdominal examination
  4. Suspect a complication of diverticulitis if the person is systemically unwell and presents with possible:
    1. Intra-abdominal abscess formation — suggested by an abdominal mass on examination or peri-rectal fullness on internal rectal examination (for example due to a low-lying pelvic abscess)
    2. Perforation and peritonitis —  suggested by abdominal rigidity, guarding, and rebound tenderness on examination
    3. Sepsis — suggested by skin discolouration, raised or lowered temperature, rigors, change in conscious level or confusion, rapid pulse, and reduced urination
    4. Stricture and fistula formation — the presence of faecaluria, pneumaturia, or pyuria may suggest colovesical fistula
    5. Intestinal obstruction  suggested by colicky abdominal pain, constipation, vomiting, inability to pass flatus, and abdominal distention

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Management of diverticulosis (asymptomatic diverticula)

If a person has confirmed diverticulosis, provide the following advice:

  1. If asymptomatic diverticulosis has been found incidentally while investigating other symptoms, no further investigations are needed
    1. The gut and liver disease charity CORE provides support for patients and families and has a patient information leaflet Information about diverticular disease
  2. Recommend eating a healthy, balanced diet and having regular meals:
    1. The person's diet should contain whole grains, fruits, and vegetables
      1. The Association of UK Dietitians has useful Food Fact Sheets on Fibre and Fruit and vegetables - how to get five-a-day
      2. NHS Choices has a useful patient information leaflet Diverticular disease and diverticulitis - prevention
    2. Fibre intake should be increased gradually (to minimize flatulence and bloating) — adults should aim to consume 30 g of fibre per day to reduce the risk of developing symptomatic diverticular disease
    3. Public Health England's booklet The Eatwell Guide has patient information on eating a healthy, balanced diet
  3. Recommend drinking an adequate fluid intake with a high-fibre diet, especially if there is a risk of dehydration
    1. The Association of UK Dietitians has a useful Food Fact Sheet on Fluid
  4. Routine follow-up is not necessary if there is no progression to symptomatic diverticular disease or diverticulitis

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Management of symptomatic diverticular disease in primary care

  1. If a person has suspected diverticular disease, but the diagnosis has not been confirmed, arrange a routine referral to a specialist in colorectal surgery to confirm the diagnosis
  2. Arrange urgent admission if a person has diverticular disease with significant rectal bleeding (for example, if the person is haemodynamically unstable), as urgent blood transfusion may be required
  3. If a person is symptomatic but does not need admission:
    1. Advise on sources of information and support, such as:
      1. the gut and liver disease charity CORE, which provides support for patients and families and has a patient information leaflet Information about diverticular disease and a fact sheet Diverticular disease
      2. the NHS Choices patient information leaflets Diverticular disease and diverticulitis - prevention and Diverticular disease and diverticulitis - treatment
    2. Recommend eating a healthy, balanced diet containing whole grains, fruits, and vegetables.
      1. The Association of UK Dietitians has useful Food Fact Sheets on Fibre and Fruit and vegetables - how to get five-a-day
      2. Public Health England's booklet The Eatwell Guide has patient information on eating a healthy, balanced diet
    3. Recommend drinking an adequate fluid intake with a high-fibre diet, especially if there is a risk of dehydration.
      1. The Association of UK Dietitians has a useful Food Fact Sheet on Fluid
    4. Consider prescribing bulk-forming laxatives if a high-fibre diet is insufficient or unacceptable, or if symptoms of constipation or diarrhoea persist
    5. Advise on the use of analgesia, such as paracetamol as-needed, if the person has ongoing abdominal pain
  4. Arrange to review the person, after one month, depending on clinical judgement
  5. Consider arranging referral to a specialist in colorectal surgery if there are persistent or refractory symptoms:
    1. Despite optimal management in primary care
    2. That cannot be explained by a possible alternative cause

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Management of acute diverticulitis in primary care

Arrange urgent hospital admission for specialist investigations and management if there is suspected acute diverticulitis and the person:

  1. Has a suspected complication, such as rectal bleeding that may require urgent blood transfusion; bowel perforation; peritonitis; or abscess
  2. Has symptoms such as severe abdominal pain which cannot be managed in primary care
  3. Is dehydrated or at risk of dehydration and is unable to take or tolerate oral fluids at home
  4. Is unable to take or tolerate oral antibiotics (if needed) at home
  5. Is frail and/or has significant co-morbidities and/or is immunocompromised (for example has diabetes mellitus, end-stage chronic kidney disease, malignancy, cirrhosis, or is taking immunosuppressive drugs)

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Manage the person in primary care if there is suspected mild, uncomplicated diverticulitis, depending on clinical judgement:

  1. Consider prescribing oral antibiotics if there is suspected infection
  2. Consider watchful waiting if the person is systemically well, has no co-morbidities, and there is no suspected infection
  3. Advise on the use of analgesia, such as paracetamol as-needed
  4. Recommend clear liquids only, with a gradual reintroduction of solid food if symptoms improve over the following 2–3 days
  5. Consider checking bloods for raised white cell count and CRP, which may suggest infection

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If the person is managed in primary care, arrange a review within 48 hours, or sooner if symptoms worsen

  1. Arrange urgent hospital admission if symptoms persist or deteriorate despite management in primary care

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Consider arranging referral to a specialist in colorectal surgery if a person is managed in primary care and has frequent or severe recurrent episodes of acute diverticulitis

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Abdominal Pain Poster

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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