Diverticular Disease
Diverticular disease can occur throughout the gastrointestinal tract but is seen most commonly in the sigmoid and descending colon. A diverticulum consists of a herniation of mucosa through the thickened colonic muscle.
Diverticulosis is defined as the presence of diverticula which are asymptomatic.
Diverticular disease is defined as diverticula associated with symptoms. These include abdominal pain (usually left lower abdominal pain), constipation, diarrhoea, change in bowel habit, rectal bleeding, bloating. Be aware that in a minority of people and in people of Asian origin, pain and tenderness may be localised in the right lower quadrant.
Diverticulitis is defined as evidence of diverticular inflammation (fever, tachycardia) with or without localised symptoms or signs.
The presence of diverticula is very common in the UK. It occurs in 5-10% of people aged 45 years and older. In people aged 85 years and older, it occurs in 80%. It is rare before the age of 40 but the disease is more virulent in young patients, with a high risk of recurrences or complications.
Approximately 75% of people with diverticula have asymptomatic diverticulosis.
Risk Factors
The main risk factors are age over 50 years and low dietary fibre.
Obesity is an important risk factor in young people.
Complicated diverticular disease has increased frequency in patients who smoke, use NSAIDs and those who are obese and
R.C 06-03-23
Who to refer:
Consider same-day assessment for patients with Diverticular Disease/Diverticulitis when:
- Pain cannot be managed with simple analgesics.
- Hydration cannot be easily maintained with oral fluids
- Rectal bleeding causing patient to be haemodynamically compromised +/- may require transfusion.
- Symptoms persist after 48 hours despite conservative management at home.
- Features of complicated diverticulitis – sepsis, obstruction, bowel perforation or peritonitis, abdominal mass, fistula.
- Patient 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).
Outpatient referral:
- When there is any doubt about diagnosis.
- Persistent symptoms despite Primary Care Management
How to refer:
Via Sci Gateway to Colorectal Surgeons at WGH for outpatient referrals
Via Flow Centre for same-day assessment
Thorough assessment
- History. Exclude red flag symptoms. Symptoms of diverticular disease are often similar to those of Colorectal cancer. Patients need to be referred via the “Urgent Suspicion of Cancer” pathway if there is any doubt about the diagnosis.
- Perform an abdominal examination and digital rectal examination.
- Consider other diagnoses, including other abdominal, urological and gynaecological causes.
- Investigations may be appropriate. FBC and CRP may help to differentiate between uncomplicated diverticular disease and diverticulitis. Other blood tests, Coeliac screen, Faecal Calprotectin, CA125 etc may be appropriate for some patients in helping to make a diagnosis.
Diverticulosis
High fibre diet with adequate fluids. Adults should aim to consume 30 g of fibre per day to reduce the risk of developing symptomatic diverticular disease. Encourage the intake of wholegrains, fruit and vegetables.
Symptomatic diverticular disease
High fibre diet. A gradual increase in fibre may obviate flatulence and bloating.
Exercise.
Encourage weight loss if the person is overweight or obese.
Stop smoking.
Adequate fluid intake. Aim for 1.5-2 litres’ day.
Bulk-forming laxatives (Ispaghula husk, Methylcellulose, Sterculia) may be beneficial to supplement the diet if a high-fibre diet is not effective or acceptable, or if constipation or diarrhoea occurs.
Paracetamol can be used for pain relief if required. Avoid NSAIDs and opioid analgesia.
Antispasmodics (Hyoscine butylbromide, Mebeverine hydrochloride) may help abdominal cramping.
Diverticulitis
Some patients with mild, uncomplicated diverticulitis may be suitable to be managed at home.
Consider a no antibiotic strategy and advise the person to seek medical help if symptoms persist or deteriorate. Arrange a review within 48 hours or sooner if symptoms worsen.
Paracetamol can be used for pain. Avoid NSAIDs and Opioid analgesia because they may increase the chance of diverticular perforation.
Recommend clear fluids only initially. Then gradually reintroduce solid food as symptoms improve over 2-3 days.
Consider checking bloods for raised white cell count and C-reactive protein (CRP), which may suggest infection.
Criteria for same-day admission are detailed in “who to refer”.
NICE guideline 147
