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Diverticulitis
Left iliac fossa pain in an older adult — know who can go home and who needs a CT. Most uncomplicated diverticulitis settles with simple measures, and antibiotics aren't always needed. Your job is to spot complications (abscess, perforation, obstruction, fistula, bleeding) and make sure the patient gets a colonic investigation later. Built for revision, not live patient decisions.
Settle them, and check the basics
complicated or not?Red flags — what each should make you think
Not everyone with diverticulitis needs antibiotics. NICE suggests a no-antibiotic approach for people who are systemically well with uncomplicated disease. But anyone systemically unwell, immunosuppressed or with significant comorbidity should get them.
First actions
- 💊Analgesia
- 🩸Bloods
- ℞Antibiotics if indicated
- CTCT abdomen/pelvis (contrast)
- IVFluids
- ☎Surgical review
Understand the patient
uncomplicated vs complicatedTypical picture
- Constant LIF pain and tenderness, fever, raised CRP; change in bowel habit
- Older adults (but increasing in younger, obese patients)
- Right-sided diverticulitis is more common in people of Asian descent
Complications and their management
- Abscess — small: antibiotics; larger (often 3 cm or more): radiological drainage
- Perforation — purulent or faecal peritonitis: emergency surgery (Hartmann's procedure, resection with anastomosis, or laparoscopic lavage in selected cases)
- Fistula — colovesical (pneumaturia), colovaginal: elective surgery
- Obstruction / stricture — consider cancer
- Bleeding — usually painless, self-limiting; CT angiogram if ongoing
After recovery: arrange colonoscopy or CT colonography (often about 6 weeks later) if the colon hasn't been assessed recently, to exclude cancer.
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Generalised peritonism, septic shock.
CT.
Resuscitation, antibiotics, emergency surgery. See the perforation page.
Not improving, swinging fever, tender mass.
CT.
Antibiotics ± radiological drainage.
Weight loss, anaemia, change in bowel habit, stricture on CT.
Colonoscopy/CT colonography after the acute episode.
2-week-wait/colorectal team.
LIF pain with bloody diarrhoea (ischaemic colitis), or pulsatile mass/shock (AAA).
CT.
Treat the actual cause.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
CT abdomen/pelvis with contrast
Later
How the plan comes together
disposition · handoverhome
Systemically well, pain controlled with paracetamol, tolerating fluids: no-antibiotic approach or oral antibiotics per NICE; review if not improving in 48 h or worse.
admit
Uncontrolled pain, can't tolerate fluids or oral antibiotics, frail/comorbid, or complications.
Hand over: CT findings, antibiotics, surgical review.
Uncomplicated and well? Simple analgesia and close review. Unwell or complicated? Antibiotics, CT and the surgeons. And always plan a later look at the colon. Nicely done getting here.
Clerking template
copy or downloadDiverticulitis — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for diverticulitis?
- Peritonism, sepsis — think perforation
- Persistent fever, tender mass — think abscess
- Pneumaturia, faecaluria, recurrent UTIs — think colovesical fistula
- Distension, no flatus — think obstruction / stricture
- Large painless rectal bleed — think diverticular bleed
- Weight loss, anaemia — think colorectal cancer
What is the initial management of diverticulitis?
- Analgesia — paracetamol; NICE advises avoiding NSAIDs and opioids where possible (perforation risk)
- Bloods — FBC, CRP, U&E, lactate if unwell
- Antibiotics if indicated — systemically unwell, immunosuppressed, comorbid: e.g. co-amoxiclav per NICE/local policy
- CT abdomen/pelvis (contrast) — if complications suspected — within 24 h of admission
- Fluids — if unable to drink
- Surgical review — complicated disease
Always alongside senior support and your local guideline.
What diagnoses must you not miss in diverticulitis?
- Perforated diverticulitis — peritonitis
- Diverticular abscess — mass · persisting fever
- Colorectal cancer (mimic) — weight loss · anaemia
- Ischaemic colitis / AAA (mimics) — older · vascular
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for diverticulitis?
- Bloods — FBC, CRP, U&E, LFT, lactate if unwell.
- CT abdomen/pelvis with contrast — Suspected complications, admitted patients (within 24 h), diagnostic uncertainty.
- Later — About 6 weeks after recovery if not recently done.
Admit or discharge: how is the plan decided for diverticulitis?
- Home — Systemically well, pain controlled with paracetamol, tolerating fluids: no-antibiotic approach or oral antibiotics per NICE; review if not improving in 48 h or worse.
- Admit — Uncontrolled pain, can't tolerate fluids or oral antibiotics, frail/comorbid, or complications.
Is there a clerking template for diverticulitis?
Yes — there is a free clerking template for diverticulitis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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