Where to refer a patient with severe colonic diverticulosis?

Referral for Severe Colonic Diverticulosis

Patients with severe colonic diverticulosis should be referred to a colorectal surgeon for consultation, particularly if they have complicated diverticulitis, are immunocompromised, or have recurrent episodes requiring consideration of elective resection. 1

When to Refer to Colorectal Surgery

Immediate/Urgent Surgical Consultation Required:

• Complicated diverticulitis including perforation with peritonitis, large abscesses not amenable to percutaneous drainage, fistula formation, or obstruction 1
• Immunocompromised patients (on corticosteroids, chemotherapy, or post-transplant immunosuppression) after recovery from an acute episode, as they are at high risk for complicated recurrence 1, 2
• Failure to improve with medical management or clinical deterioration during treatment 2
• Severe systemic illness or sepsis requiring aggressive intervention 1, 2

Elective Surgical Consultation Appropriate:

• Recurrent diverticulitis with ongoing symptoms affecting quality of life, though the decision should be individualized based on immune status, severity of prior episodes, patient preferences, and operative risks 1
• After successful non-operative management of complicated diverticulitis in immunocompromised patients to discuss preventive resection 1

Important caveat: Elective colectomy should NOT be routinely recommended for immunocompetent patients with recurrent uncomplicated diverticulitis solely to prevent complications, as complicated diverticulitis is usually the first presentation and becomes less likely with recurrences 1

When to Refer to Gastroenterology

Diagnostic Evaluation:

• After acute episode resolution (6-8 weeks) for colonoscopy to rule out colorectal cancer, especially after complicated diverticulitis (7.9% cancer risk) or first episode of uncomplicated diverticulitis (1.3% cancer risk) 3, 4
• Diagnostic uncertainty when imaging is needed or alternative diagnoses must be excluded 3, 4

Medical Management:

• Recurrent symptoms requiring optimization of preventive strategies including dietary modification, fiber supplementation, and consideration of rifaximin therapy 3
• Ongoing abdominal symptoms after recovery to evaluate for non-inflammatory causes (bile acid malabsorption, functional disorders) versus persistent inflammation 1

Key Clinical Pitfalls to Avoid

• Do not delay surgical consultation in immunocompromised patients, as they may present with milder symptoms despite severe disease and have higher risk of progression 1, 2
• Do not assume surgery eliminates recurrence risk: at 5-year follow-up, 15% of patients who underwent elective surgery still experienced recurrent diverticulitis 1
• Do not expect surgery to resolve all chronic symptoms: 22-25% of patients continue to have abdominal pain after colectomy 1
• Recognize that long-term rates of emergency surgery or death are low (5%) even after complicated diverticulitis managed conservatively, and elective resection was not associated with reduced emergency surgery or death rates 1

Multidisciplinary Approach for Severe Cases

For hospitalized patients with severe diverticulitis requiring inpatient management, coordinate care between gastroenterology and colorectal surgery early, with involvement of dietitian and pharmacist as needed 2. This mirrors the multidisciplinary approach proven effective in other severe gastrointestinal conditions 1.