I thought diverticular disease and diverticulosis were synonyms, but in fact diverticular disease refers to symptomatic diverticula. Diverticulitis, obviously, refers to inflammation/infection. Symptoms of diverticular disease can include:
- Lower abdominal pain
- Altered bowel habit
- PR bleeding
Diverticulitis usually presents with fever/malaise associated with the abdominal pain. Large PR bleeds can also occur. If an exacerbation is suspected but there are no systemic symptoms, a WCC & CRP can be helpful in looking for signs of inflammation. CRP results >25 are associated with complicated diverticulitis.
Diverticulitis may require hospital admission for systemic antibiotics if severe, but if treated orally in the community the antibiotics recommended by NICE are:
- If penicillin-allergic – second choice is ciprofloxacin + metronidazole.
Non-resolution of symptoms by 48 hours is an indication for admission.
Although some evidence is starting to suggest that it’s possible to manage mild cases of diverticulitis without antibiotics, the evidence is not yet strong enough to act on and thus antibiotics are always recommended.
Remember to exclude other causes for symptoms before attributing them to diverticular disease. CT colonography is replacing barium enema as a test as more sensitive/specific. Colonoscopy is still in use.
Management of diverticular disease is with a high-fibre diet (18 – 30g fibre daily), adequate fluid intake, and stool-bulking laxatives if needed. Patients with diarrhoea-predominant disease should still aim for that level of fibre intake but might be best advised to aim for taking more of it in the form of stool-bulking soluble fibre such as oats, rather than fruit and vegetables. In general, a mix of whole grains, fruit, and vegetables is advised – too much bran/cereal fibre can cause bloating. Note that fibre should be introduced gradually and that the effects of a high-fibre diet can take up to four weeks to become apparent.
Analgesia should ideally be with paracetamol rather than NSAIDs (associated with a higher risk of complications such as perforation) or opioids (constipation). Tramadol may be useful in the short term only. Antispasmodics are not recommended by NICE, but don’t actually appear to be contraindicated. If paracetamol isn’t controlling the pain adequately, this is an indication for secondary care referral. Other indications include new/red flag symptoms, or symptoms interfering with quality of life.
(Pulse on-line learning module)