From the Guidelines
When evaluating a patient with suspected acute diverticulitis, key history questions should focus on abdominal pain characteristics, associated symptoms, and risk factors, as outlined in the American College of Physicians guideline 1. To guide diagnostic testing and treatment decisions, a thorough history is essential.
Key History Questions
- Ask about the location (typically left lower quadrant), onset, duration, and severity of pain.
- Inquire about fever, nausea, vomiting, changes in bowel habits (constipation or diarrhea), and urinary symptoms.
- Document any previous episodes of diverticulitis, as recurrence is common, with a reported rate of recurrence at 10 years of 22% or 55%, respectively 1.
- Ask about diet, particularly low-fiber intake which is a risk factor.
- Note use of medications that increase risk, such as NSAIDs, steroids, or opioids.
- Assess for complications by asking about severe pain, inability to pass gas or stool, and symptoms of sepsis.
- Determine risk factors including age (more common over 40), obesity, smoking status, and physical inactivity. This information is crucial in distinguishing diverticulitis from other conditions like irritable bowel syndrome, appendicitis, or gynecological issues in women.
Importance of History in Diagnosis and Management
A thorough history helps guide appropriate diagnostic testing, such as the use of computed tomography (CT) imaging when there is diagnostic uncertainty 1, and treatment decisions, which may range from outpatient antibiotics to hospitalization depending on severity. Additionally, the AGA clinical practice update on medical management of colonic diverticulitis provides practical and evidence-based advice for diverticulitis management, including the use of antibiotic treatment selectively, rather than routinely, in immunocompetent patients with mild acute uncomplicated diverticulitis 1. By prioritizing a thorough history, clinicians can provide personalized care and reduce the risk of recurrence, as recommended by the American College of Physicians guideline 1 and the AGA clinical practice update 1.
From the Research
Symptoms and Diagnosis
- Patients with acute diverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever 2
- Other symptoms may include anorexia, constipation, nausea, diarrhea, and dysuria 2
- Initial laboratory studies include a complete blood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein 2
- Computed tomography (CT) is the most commonly performed imaging test to establish the diagnosis and the extent and severity of disease, and to exclude complications in selected patients 2, 3, 4, 5
Classification and Management
- Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms, and patient history 4
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 4
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2, 4, 6
- For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3-5 cm should be drained percutaneously 4, 5
Treatment and Prevention
- Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non-operative management 4
- Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 2, 4
- Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, cessation of smoking, and, in persons with a body mass index of 30 kg per m(2) or higher, weight loss 2
- CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age 3