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Diverticular disease

About

What is covered

This NICE Pathway covers the diagnosis and management of diverticular disease in people aged 18 years and over. It aims to improve diagnosis and care and help people get timely information and advice, including advice about symptoms and when to seek help.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diverticular disease in an interactive flowchart

What is covered

This NICE Pathway covers the diagnosis and management of diverticular disease in people aged 18 years and over. It aims to improve diagnosis and care and help people get timely information and advice, including advice about symptoms and when to seek help.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Computed tomographic colonography (virtual colonoscopy) (2005) NICE interventional procedures guidance 129

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Symptoms and signs that suggest complicated acute diverticulitis

Symptom or sign
Possible complication
Abdominal mass on examination or peri-rectal fullness on digital rectal examination
Intra-abdominal abscess
Abdominal rigidity and guarding on examination
Bowel perforation and peritonitis
Altered mental state, raised respiratory rate, low systolic blood pressure, raised heart rate, low tympanic temperature, no urine output or skin discolouration
Faecaluria, pneumaturia, pyuria or the passage of faeces through the vagina
Fistula into the bladder or vagina
Colicky abdominal pain, absolute constipation (passage of no flatus or stool), vomiting or abdominal distention
Intestinal obstruction

Antibiotics for adults aged 18 years and over with suspected or confirmed acute diverticulitis

AntibioticSee BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
Dosage and course lengthA longer course may be needed based on clinical assessment. Continue antibiotics for up to 14 days in people with CT-confirmed diverticular abscess.
First-choice oral antibiotic for suspected or confirmed uncomplicated acute diverticulitis
Co-amoxiclav
500/125 mg three times a day for 5 days
Alternative first-choice oral antibiotics if penicillin allergy or co-amoxiclav unsuitable
Cefalexin (caution in penicillin allergy) with metronidazole
Cefalexin: 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infection) for 5 days
Metronidazole: 400 mg three times a day for 5 days
Trimethoprim with metronidazole
Trimethoprim: 200 mg twice a day for 5 days
Metronidazole: 400 mg three times a day for 5 days
Ciprofloxacin (only if switching from IV ciprofloxacin with specialist advice; consider safety issuesSee MHRA advice for restrictions and precautions for using fluoroquinolones due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).) with metronidazole
Ciprofloxacin: 500 mg twice a day for 5 days
Metronidazole: 400 mg three times a day for 5 days
First-choice intravenous antibioticsReview intravenous antibiotics within 48 hours or after scanning if sooner and consider stepping down to oral antibiotics where possible. for suspected or confirmed complicated acute diverticulitis
Co-amoxiclav
1.2 g three times a day
Cefuroxime with metronidazole
Cefuroxime: 750 mg three or four times a day (increased to 1.5 g three or four times a day if severe infection)
Metronidazole: 500 mg three times a day
Amoxicillin with gentamicin and metronidazole
Amoxicillin: 500 mg three times a day (increased to 1 g four times a day if severe infection)
Gentamicin: Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentrationTherapeutic drug monitoring and assessment of renal function is required (BNF, August 2019).
Metronidazole: 500 mg three times a day
CiprofloxacinOnly in people with allergy to penicillins and cephalosporins. (consider safety issues) with metronidazole
Ciprofloxacin: 400 mg twice or three times a day
Metronidazole: 500 mg three times a day
Alternative intravenous antibiotics
Consult local microbiologist

Factors to take into account when deciding whether to have lavage or resection for diverticular perforation with generalised peritonitis

Laparoscopic lavage
Resectional surgery
What the procedure involves
In diverticulitis this involves washing the abdominal cavity and colon using keyhole surgery.
The surgical removal of the diseased colon followed by either reattaching the remaining segments of the colon or forming an end stoma.
Effect on quality of life
There was no significant difference in quality of life scores reported for lavage and surgery.
Mortality
Although there was some benefit seen in mortality for lavage, this evidence was very uncertain.
Needing a stoma (where the bowel is connected surgically to an opening in the abdomen and stools are collected in a bag or pouch)
A stoma is not needed.
A stoma may be needed.
Pain
Less likely to relieve pain than resectional surgery.
More likely to relieve pain than lavage because the damaged bowel has been removed.
Recurrent diverticulitis
Fewer people had recurrent diverticulitis after surgery than after lavage because the diseased bowel is removed. However, the evidence was very uncertain.
Needing more operations
Evidence comparing unplanned surgery with lavage showed that fewer people needed reoperations after surgery than after lavage.
Evidence that included unplanned surgery and planned surgery (scheduled stoma reversal after resectional surgery) showed that fewer people needed reoperations after lavage.
However, in both cases the evidence was very uncertain.
Postoperative complications
There was no meaningful difference in the number of infections or in the need for further intervention between lavage and surgery. People who had surgery had a greater reduction in post-surgical abscesses than those who had lavage, but this evidence was of low quality.
Advise people to eat a healthy, balanced diet including whole grains, fruit and vegetables. Tell them that:
  • there is no need to avoid seeds, nuts, popcorn or fruit skins
  • if they have constipation and a low-fibre diet, increasing their fibre intake gradually may minimise flatulence and bloating.
Advise people to drink adequate fluid if they are increasing their fibre intake, especially if there is a risk of dehydration.
Tell people about the benefits of exercise, and weight loss if they are overweight or obese, and stopping smoking, in reducing the risk of developing acute diverticulitis and symptomatic disease.

Glossary

(sudden inflammation or infection associated with diverticula; symptoms include constant abdominal pain, usually severe and localising in the left lower quadrant; other features, including fever, may also be present)
(inflammation of the bowel related to Crohn's disease, ulcerative colitis, ischaemia or microscopic colitis; symptoms may include abdominal pain and change in bowel habits with passage of blood)
(the presence of complications associated with inflamed or infected diverticula; these complications may include abscess, fistula, stricture perforation and sepsis)
(the presence of diverticula with mild abdominal pain or tenderness and no systemic symptoms)
(the presence of diverticula without symptoms)

Paths in this pathway

Pathway created: November 2019 Last updated: November 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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