Diverticular Disease

Condition

Common — affects 1 in 3 people over 60 in the western world. Diverticulosis (the presence of diverticula) is symptomless; diverticulitis (inflammation of diverticula) is symptomatic.

Murtagh’s triad: acute pain + left-sided radiation + fever suggests acute diverticulitis.

History

Constipation, or alternating diarrhoea/constipation; low-fibre diet; pain in the left iliac fossa, often intermittent cramping; bleeding — can be profuse ± faeces; may present as an acute abdomen or subacute obstruction; usually settles within 2–3 days.

Examination

For diverticulitis: check BP, pulse, temperature. Abdominal tenderness, may be localised to the left iliac fossa. If PR bleeding, perform a PR examination to rule out haemorrhoids.

Investigations

FBC (WCC elevated in diverticulitis); consider an inflammatory marker (CRP/ESR); sigmoidoscopy or barium enema to confirm the diagnosis. If presenting as an acute abdomen, CT abdomen with contrast to look for inflammation and microperforation.

Management

Diverticulitis: assess the need for general surgery assessment/admission. Uncomplicated diverticulitis (without perforation, peritonitis, sepsis/septic shock, or an abscess >5cm) may not require antibiotic therapy. Give antibiotics if uncomplicated but the patient is immunocompromised, has right-sided diverticulitis, or fails to improve after 72 hours of conservative treatment: amoxicillin + clavulanate 875+125mg orally twice daily for 5 days, or (if penicillin allergic) trimethoprim/sulfamethoxazole 160/800mg twice daily plus metronidazole 400mg twice daily for 5 days. Light diet until symptoms resolve; laxative if required.

Monitor for complications: abscess, perforation, peritonitis, obstruction, fistula (bladder, vagina).

Diverticular disease (prevention/maintenance): maintain a high-fibre diet — daily insoluble fibre from cereals, wholegrain bread, fruit, and vegetables. Maintain regular bowels and avoid constipation; adequate fluid intake.

Diverticular bleeding: given the possibility of massive bleeding, admit for observation, fasting, and IV fluids. Bleeding stops spontaneously in 75% of people. If haemostasis is required, achieve it by urgent colonoscopy with direct endoscopic treatment of the bleeding vessel, or by selective angiography with embolisation of the bleeding vessel.