Acute Diverticulitis

Publication: 01/04/2009  
Last review: 19/01/2019  
Next review: 19/01/2022  
Clinical Guideline
CURRENT 
ID: 1413 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for Investigation and Management of Acute Diverticulitis in Adults

  • Treatment Algorithm
  • Summary
    Acute Diverticulitis

    History

    • Diverticulitis classically presents with constant abdominal pain – usually left lower quadrant.
    • Often associated with fevers/chills, shivering/sweating, nausea, vomiting, constipation or diarrhoea.

    Examination

    • Check for left lower quadrant tenderness, guarding or rebound tenderness.
    • Check temperature and basic physiological measurements.
    • Diverticulitis is classified as complicated or uncomplicated. Physical examination may be sufficient to exclude complicated diverticulitis.
      • Complicated diverticulitis: defined as acute diverticulitis accompanied by abscess, fistula, bowel obstruction, or free intra-abdominal perforation. These complications are normally confirmed radiologically but may be suspected clinically e.g. peritonism.
      • Uncomplicated diverticulitis: defined as diverticulitis without evidence of complications as listed above.
    • Assess if the patient has Systemic inflammatory response syndrome (SIRS). SIRS= ≥2 of: Body temperature < 36 °C or > 38 °C , Heart rate > 90 bpm, respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) White blood cell count < 4 × 109 or > 12 × 109 cells/L.
    • Assess if there is evidence of sepsis. Sepsis is SIRS of an infective aetiology. The aetiology of acute diverticulitis is not clear. There is increasing evidence for an inflammatory process.

    Initial investigations required

    • FBC, U&Es.
    • Blood cultures in all cases of suspected complicated diverticulitis or if evidence of systemic infection. Please see LTHT guidance for blood culture sampling in adults
    • Mid stream specimen of urine (MSU) (if clinically indicated).
    • Arterial blood gas (if evidence of complicated diverticulitis or SIRS suspected).
    • Abdominal X-ray (supine).
    • CT Abdomen with intravenous contrast may be indicated.

    Non-Antimicrobial Management

    • Intravenous fluid replacement
    • Analgesia
    • Surgical correction of complications if required.
    • Aspiration/drainage of abscesses >2cm diameter

    Empirical antimicrobial treatment
    Empirical therapy at presentation is based on disease severity as determined by clinical history and examination. Disease severity is classified as:

    • Acute diverticulitis with severe sepsis
    • Complicated acute diverticulitis or diverticulitis + sepsis
    • Uncomplicated acute diverticulitis

    Antimicrobial Regimen

    <65yrs

    ≥65 yrs

    Allergy to penicllins and/or cephalosporins (any age)

    Acute diverticulitis with severe sepsis

    See Severe Sepsis Screening Tool and Resuscitation Care Bundle (Adults)

    Complicated acute diverticulitis OR diverticulitis + sepsis

    IV Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly plus
    IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg 8-hourly

    IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly

    Ciprofloxacin IV 400mg 12-hourly plus
    IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg 8-hourly

    Uncomplicated acute diverticulitis without SIRS

    Antibiotics are not normally indicated

    Uncomplicated acute diverticulitis with SIRS

    Individual clinical assessment may dictate whether a patient is treated with antibiotics or observed for their clinical response without antibiotic therapy. See text for detailed information.

    Review
    Review antibiotic therapy with CT results and treat as complicated or uncomplicated.
    Complicated diverticulitis patients should normally be under the care of colorectal surgeons
    Follow up
    Luminal investigation should be undertaken after approximately 6/52 to rule out colonic malignancy.

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    Background
    • Diverticulosis can be defined as the presence of diverticula in the colon. This affects the sigmoid colon in 95% of cases.
    • Prevalence correlates with age. 30% of the population is affected by the age of 60 years and 60% are affected by the age of 80 years.
    • 10 to 25% of patients with diverticulosis will develop diverticulitis.
    • The aetiology of diverticulitis is unclear and may represent an inflammatory condition.
    • The aetiology of acute diverticulitis is also unclear. It may be acute inflammation of the diverticula, infection or microperforation. These aetiologies may be complicated by perforation and fistulae formation, bowel obstruction and abscess formation. [Evidence Level B]

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    Clinical Diagnosis

    History:

    • Diverticulitis classically presents with constant abdominal pain most frequently occurring in the left lower quadrant. The location may vary depending on the site of disease.
    • Evidence of systemic inflammation may be found such as fevers/chills, shivering, and sweating.
    • Other associated symptoms commonly found are nausea, vomiting, constipation or diarrhoea.

    Examination:

    • The patient may be febrile.
    • Tenderness is found in the left lower quadrant.
    • Diverticulitis is classed as complicated or uncomplicated diverticulitis:
      • Complicated diverticulitis can be defined as acute diverticulitis accompanied by abscess, fistula, bowel obstruction, or free intra-abdominal perforation. Complicated diverticulitis may be suggested on examination by fever, tachycardia, hypotension, tachypnoea and guarding or rebound tenderness [Evidence Level B].
      • Uncomplicated diverticulitis can be defined as acute diverticulitis without the complicating features present in complicated diverticulitis.
      • Uncomplicated diverticulitis may be associated with systemic inflammatory response syndrome (SIRS)
        • SIRS: ≥2 of: Body temperature < 36 °C or > 38 °C , Heart rate > 90 bpm, respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) White blood cell count 4 × 109 or > 12 × 109 cells/L.
        • Assess if there is evidence of sepsis. Sepsis is SIRS of an infective aetiology. The aetiology of acute diverticulitis is not clear. There is increasing evidence for an inflammatory process. [Evidence Level B-C]

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    Investigation
    • FBC, U&E’s. [Evidence Level C]
    • Blood cultures in all cases of suspected complicated diverticulitis or if evidence of sepsis (SIRS of an infective origin). Please see LTHT guidance for blood culture sampling in adults [Evidence Level C]
    • Mid stream specimen of urine (MSU) [Evidence Level C]
    • Arterial Blood Gas (if evidence of complicated disease or sepsis) [Evidence Level D]
    • Abdominal X-ray (supine) [Evidence Level C]
    • Chest X-ray and lateral decubitus abdominal X-ray are not routinely indicated.
    • CT Abdomen with intravenous contrast may be indicated. It is recommended where complicated diverticulitis is suspected but may also be useful outside this indication. [Evidence Level B]
    • CT (contrast enhanced abdomen/pelvis CT) risks are as follows: typical scan gives an effective dose of 7mSv. The average risk of fatal cancer associated with this is approximately 1 in 2900 for someone of working age (18-65 years old). These estimates are based on a risk coefficient of 1 in 20000 per mSv.
    • Pus sample (in sterile universal rather than pus swabs) for microbiology from abscess/collection aspirated/drained. [Evidence Level C]

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    Treatment
    Non-Antimicrobial Treatment

    Hospitalisation is required for patients with evidence of significant inflammation, unable to take oral fluids, older than 85 years or with significant co-morbidity (e.g. cardiorespiratory disease, immunosuppression etc.) [Evidence Level C]

    Non-antimicrobial management

    • Intravenous fluid replacement
    • Analgesia
    • Surgical correction of complications if required.
    • Aspiration/drainage of abscesses >2cm diameter

    [Evidence level C]

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    Empirical Antimicrobial Treatment

    Empirical therapy at presentation is based on disease severity as determined by clinical history and examination. Disease severity is classified as:

    • Acute diverticulitis with severe sepsis
    • Complicated acute diverticulitis or diverticulitis + sepsis
    • Uncomplicated acute diverticulitis

    A decision to treat with antibiotics should be reviewed if a radiological diagnosis of uncomplicated diverticulitis is made following a clinical diagnosis of complicated diverticulitis.

    Acute diverticulitis with severe sepsis
    See Severe Sepsis Screening Tool and Resuscitation Care Bundle (Adults)

    Severe sepsis definition: An infection + SIRS + organ dysfunction e.g. hypotension, poor urine output, hypoxaemia, metabolic acidosis, clotting abnormalities or new confusion/altered mental status.
    SIRS: ≥ 2 of the following: Body temperature < 36 °C or > 38 °C , Heart rate > 90 bpm, Respiratory rate > 20 breaths per minute or, on blood gas, a PaCO2 less than 32 mm Hg (4.3 kPa) White blood cell count 4 × 109 or > 12 × 109 cells/L.

    Complicated Acute Diverticulitis (based on clinical radiological findings) or diverticulitis + sepsis:

    Antimicrobial Regimen
    [Evidence Level C]

    <65yrs

    ≥65 yrs

    Allergy to penicllins and/or cephalosporins (any age)

    Complicated acute diverticulitis OR diverticulitis + sepsis

    IV Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly plus
    IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg 8-hourly

    IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5g 8-hourly

    Ciprofloxacin IV 400mg 12-hourly plus
    IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg 8-hourly

    Uncomplicated Acute Diverticulitis (based on clinical radiological findings):

    Antimicrobial Regimen
    [Evidence Level A]1.

    <65yrs

    ≥65 yrs

    Allergy to penicllins and/or cephalosporins (any age)

    Uncomplicated acute diverticulitis without SIRS

    Antibiotic therapy is not recommended

    Uncomplicated acute diverticulitis with SIRS

    Individual clinical assessment may dictate whether a patient is treated with antibiotics* or observed for their clinical response without antibiotic therapy.

    *For antimicrobial management see complicated diverticulitis pathway.

    Evidence Review

    The best evidence for the antimicrobial management of diverticulitis comes from a study published in 2012. The study was a randomised controlled trial of antibiotics vs. no antibiotics in uncomplicated diverticulitis1.

    The antibiotic group were initially treated with intravenous antibiotics (cephalsporins, carbapenems or piperacillin-tazabactem) followed by oral antibiotics (typically Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin /cefadroxil and Metronidazole electronic Medicines Compendium information on Metronidazole ) for at least 7 days.

    Patients in the study had on average

    • Severe local tenderness
    • CT evidence of uncomplicated diverticulitis
    • A CRP of ≈100 mg/L, and a WCC of ≈ 12.5x109
    • Fever of 38.10C

    Many patients in the study therefore had a diagnosis of uncomplicated diverticulitis with SIRS.

    This study found no differences in sigmoid resection rates, length of hospital stay or rate of recurrence.
    There was a non-significant higher rate of abscesses in the no antibiotic group vs. the antibiotic group (1% v. 0%).

    Therefore, for the majority of patients the use of antibiotics is not of benefit and increases their risk of complications e.g. antibiotic resistance and Clostridium difficile infection.

    This study had a number of exclusion criteria including pregnancy, immunosuppression and sepsis. This study does not therefore provide evidence applicable to all patient groups. Individual clinical assessment is therefore appropriate in the decision to treat patients with antibiotics.

    Those without antibiotic therapy should be observed in hospital until surgically assessed as fit for discharge. Antibiotics may be started during this period of observation. Ongoing/progressive abdominal symptoms and fever as well as rising inflammatory markers are likely to prompt the initiation of antibiotics. This occurred in the study by Chabok in 10 of 299 (3.4%) patients allocated to receive no antibiotics. Therefore, in those patients where a reviewing surgeon, following a clinical assessment, is not satisfied a patient is safe for discharge and observation in hospital is not possible, the risk/benefit based decision to prescribe antibiotics may therefore move towards the use of antibiotics as opposed to observation.
    Review antibiotic therapy with CT results and treat as complicated or uncomplicated.
    [Evidence Level B-C]

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    Duration of Treatment

    Complicated: Duration of therapy is dependent on clinical response (temperature, pain, CRP etc.)
    The patient is unlikely to require more than 14 days therapy. [Evidence Level C]

    Uncomplicated: Where it is indicated treatment is unlikely to be needed for more than 5 days. [Evidence Level C]

    Follow up

    Luminal investigation should be undertaken after approximately 6/52 to rule out colonic malignancy.

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    Switch to oral agent(s)

    Antibiotic route of administration should be reviewed at 48 hours.
    Oral antibiotic/oral step-down is not age dependent: PO Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg 8-hourly
    [Evidence Level C]

    Allergy to penicllins and/or cephalosporins: PO Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly plus PO Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly [Evidence Level D]

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    Treatment Algorithm

    Antimicrobial treatment of Acute Diverticulitis

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    Provenance

    Record: 1413
    Objective:

    Aims

    • To improve the diagnosis and management of acute diverticulitis

    Objectives

    • To provide evidence-based recommendations for appropriate investigation of acute diverticulitis.
    • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of acute diverticulitis.
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    To improve the diagnosis and management of acute diverticulitis
    Clinical condition:

    Acute Diverticulitis

    Target patient group: Adults
    Target professional group(s): Secondary Care Doctors
    Pharmacists
    Adapted from:

    Evidence base

    References

    1. Chabok A. (2012). Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-539.
    2. Dan Med J. 2012 May;59(5):C4453. Danish national guidelines for treatment of diverticular disease. Andersen JC, Bundgaard L, Elbrønd H, Laurberg S, Walker LR, Støvring J.
    3. Janes, S. (2006). "Management of diverticulitis." BMJ 332: 271-275.
    4. Mizuki, A. (2005). "The out-patient management of patients with acute mild-to-moderate colonic diverticulitis." Aliment Pharmacol Ther 21: 889-897.
    5. Rafferty, J. (2006). "Practice Parameters for Sigmoid Diverticulitis." Dis Colon Rectum 49: 939-944.
    6. Salzman, H. (2005). "Diverticular Disease: Diagnosis and Treatment." American Family Physician 72(7): 1229-1234.
    7. Stollman, N. (1999). "Diagnosis and Management of Diverticular Disease of the Colon in Adults." THE AMERICAN JOURNAL OF GASTROENTEROLOGY 94(11): 3110-3121.
    8. Szojda, M. (2007). "Review article: management of diverticulitis." Aliment Pharmacol Ther 26(S2): 67-76.
    9. Sigmoid Diverticulitis: a systemic review. Arden M. Morris, Scott E. Regenbogen, Karin M. Hardiman,  Samantha Hendren, JAMA. 2014;311(3):287-297. doi:10.1001/jama.2013.282025.
    10. Sigmoid Diverticulitis: A Systematic Review Arden M. Morris, Scott E. Regenbogen, Karin M. Hardiman, Samantha Hendren, JAMA. 2014;311(3):287-297.
    11. Management of acute uncomplicated diverticulitis without antibiotics: a single centre cohort study Nina Brochmann, Johannes Schultz, Gunn Signe Jakobsen, Tom Øresland Colorectal Disease 2016, accepted article

    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 1.1

    Related information

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