What are the guidelines for referring a patient with diverticulitis (inflammation of the diverticula)?

From the Guidelines

Patients with diverticulitis should be referred to a gastroenterologist or surgeon when they have severe symptoms, complications, or recurrent episodes, as these cases may require prompt medical or surgical intervention to prevent morbidity and mortality and improve quality of life. The decision to refer a patient with diverticulitis is based on the severity of symptoms, the presence of complications, and the frequency of recurrent episodes. According to the American College of Physicians guideline on the diagnosis and management of acute left-sided colonic diverticulitis 1, the management of uncomplicated diverticulitis typically involves outpatient care, while complicated cases may require hospitalization and surgical consultation.

Key Considerations for Referral

• Severe symptoms, such as high fever, significant abdominal pain, or vomiting, may necessitate immediate referral to a specialist for further evaluation and management.
• Complications, including peritonitis, abscess formation, obstruction, fistula, or perforation, require prompt surgical intervention to prevent serious morbidity and mortality.
• Recurrent episodes of uncomplicated diverticulitis may indicate a need for elective colectomy, especially if the patient's quality of life is significantly impacted by frequent episodes.

Management of Uncomplicated Diverticulitis

For patients with uncomplicated diverticulitis, initial management may include oral antibiotics, such as ciprofloxacin and metronidazole, for 7-10 days, along with a clear liquid diet transitioning to low-fiber foods as symptoms improve 1. However, recent evidence suggests that antibiotics may not be necessary in immunocompetent patients with mild acute uncomplicated diverticulitis 1. The decision to use antibiotics should be based on individual patient factors, such as the presence of comorbidities, severity of symptoms, and risk of complications.

Importance of Colonoscopy

Patients with a history of diverticulitis should undergo colonoscopy to rule out other pathologies, such as colon cancer, and to discuss elective colectomy with a surgeon 1. The decision to perform colonoscopy should be based on individual patient factors, including the frequency and severity of diverticulitis episodes, age, and comorbidities.

Lifestyle Modifications

Patients with diverticulitis should be advised to make lifestyle modifications to reduce the risk of recurrence, including consuming a high-quality diet, maintaining a normal body mass index, engaging in regular physical activity, avoiding smoking, and avoiding nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease 1. These modifications can help improve quality of life and reduce the risk of complications.

From the Research

Diverticulitis Referral Guidelines

• Referral of patients with symptomatic diverticular disease to secondary care is not indicated unless:
  • The symptoms affect their quality of life
  • The pain is not controlled by paracetamol
  • New symptoms develop which require further investigation
  • There are concerns about the possibility of an alternative diagnosis or patients develop red flag symptoms 2
• Patients with suspected uncomplicated acute diverticulitis should be assessed according to their level of pain and associated systemic features of sepsis 2
• For patients with uncomplicated diverticulitis, outpatient treatment is recommended in afebrile, clinically stable patients 3

Diagnosis and Treatment

• Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis 3
• CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred 3
• Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management 3
• Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence in uncomplicated diverticulitis, and should only be used selectively 3, 4
• 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 3

Antibiotic Treatment

• Ceftriaxone and metronidazole was found to be non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality in patients with complicated diverticulitis 5
• However, treatment with ceftriaxone in complicated diverticulitis increases the incidence of intra-abdominal Enterococcus faecium detection 6
• A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal E. faecium 6