A 60-year-old man presents with left-sided lower abdominal pain and minor rectal bleeding. He has a known past history of diverticular disease and following a full clinical assessment you make a diagnosis of acute diverticulitis. He is clinically quite well and has no significant co-morbidities. You decide to manage him in the primary care setting. He has no known drug allergies.
- How should this patient be managed in primary care?
Diverticula are very common with approximately half of all people over the age of 50 and almost 70% of people over the age of 80 have them. Approximately 75% of people with diverticula have asymptomatic diverticulosis, and only 25% develop symptomatic disease.
Acute diverticulitis results from the inflammation or perforation of a diverticulum. This inflammation may remain localised (pericolic abscess) or spread and result in peritonitis. The typical clinical features of acute diverticulitis include:
- Abdominal pain (most prominent in the left lower quadrant)
- Left iliac fossa tenderness
- Left iliac fossa mass
- Rectal bleeding
Patients can be managed in the primary care setting primary care if there is suspected mild, uncomplicated diverticulitis (depending on clinical judgement):
- Consider prescribing oral antibiotics if there is suspected infection. If needed, prescribe at least one week of co-amoxiclav (or a combination of ciprofloxacin and metronidazole if the person is allergic to penicillin).
- Consider watchful waiting if the person is systemically well, has no co-morbidities, and there is no suspected infection.
- Advise on the use of analgesia, such as paracetamol as needed, if the person has ongoing abdominal pain.
- Avoid the use of NSAIDs and opioid analgesia if possible, due to the potential increased risk of diverticular perforation.
- Recommend clear liquids only, with gradual reintroduction of solid food if symptoms improve over the following 2–3 days.
- Consider checking bloods for raised white cell count and C-reactive protein (CRP), which may suggest infection.
- If the person is managed in primary care, arrange a review within 48 hours, or sooner if symptoms worsen.
- You manage him as above and review him 48 hours later and find that his condition has deteriorated. What should you do next?
Patients with mild acute diverticulitis that have been managed in the primary care setting should be referred for urgent hospital admission if their symptoms persist or deteriorate.
- According to the current NICE guidelines, what are the indications for urgent hospital admission in patients with acute diverticulitis?
Urgent hospital admission for specialist investigations and management should be arranged if a patient with suspected acute diverticulitis has any of the following:
- A suspected complication, e.g. rectal bleeding requiring an urgent blood transfusion, bowel perforation, peritonitis or abscess formation.
- Has symptoms, such as severe abdominal pain, which cannot be managed in primary care.
- Is dehydrated or at risk of dehydration and is unable to take or tolerate oral fluids at home.
- Is unable to take or tolerate oral antibiotics (if needed) at home.
- 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).
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