GI · Full case

Diverticulosis & Diverticulitis

NICE NG147 CKS 2024

50% at 50Diverticulosis prevalence by age 50

70% at 70Prevalence by age 70; nearly universal by 80

5% lifetimeDiverticulosis that develops diverticulitis

CRP >150Suggests complicated diverticulitis; hospital admission

30g/dayTarget fibre intake for diverticular prevention and remission

No routine antibioticsNICE NG147: watchful waiting for uncomplicated diverticulitis

10–20%Recurrence risk after first diverticulitis episode

Hinchey III/IVPurulent / faecal peritonitis → surgical emergency

📋 Clinical Stem — Left Iliac Fossa Pain with Fever and Change in Bowel Habit

A patient presents with left iliac fossa (LIF) pain, fever, change in bowel habit, and nausea, consistent with acute diverticulitis until proven otherwise.

“A 58-year-old woman presents with a 3-day history of left-sided lower abdominal pain that is constant and worsening, associated with a low-grade fever, nausea, and a change in bowel habit (looser stools than usual). She has a known history of diverticulosis diagnosed incidentally 3 years ago on a colonoscopy. She is asking for antibiotics and is worried the pain means she will need surgery.”

This stem applies to uncomplicated acute diverticulitis (managed in primary care), complicated diverticulitis (requiring hospital admission), and incidental diverticulosis management. Key clinical decision points: CRP level, systemically well vs unwell, severity classification (Hinchey), and distinguishing uncomplicated diverticulitis from complicated disease requiring hospital admission.

Scenario A — Uncomplicated Acute Diverticulitis (Community Management) 58-year-old with LIF pain + mild fever, systemically well, CRP <150, no peritonism; NICE NG147 watchful waiting without routine antibiotics; adequate analgesia, fluid advice, low-fibre diet acutely, high-fibre in remission

Scenario B — Complicated Diverticulitis (Hospital Admission) 64-year-old with LIF pain + fever 38.8°C + CRP 210 + vomiting; Hinchey I/II abscess suspected; hospital admission for IV antibiotics, CT, and surgical assessment

Scenario C — Diverticular Bleed (PR Bleeding) 70-year-old with sudden onset painless large volume fresh PR bleeding; haemodynamically compromised; 999 — massive GI haemorrhage from diverticular vessel

Scenario D — Incidental Diverticulosis Counselling 55-year-old told they have diverticulosis on a routine colonoscopy; wants to know what it means, what to eat, and whether they will need surgery

Scenario E — Recurrent Diverticulitis (Elective Surgery Discussion) 60-year-old with third episode of acute diverticulitis in 2 years; discussion of elective sigmoid colectomy indications, risks, and benefits

Key variables to adapt for Hinchey severity (I–IV), CRP level, systemically well vs unwell, prior episodes and frequency, immunocompromised status, patient preference re: antibiotics (NICE watchful waiting vs patient expectation), constipation vs diarrhoea presentation

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

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Diverticulitis typically presents with left iliac fossa pain, fever, and change in bowel habit in a middle-aged or older patient. The GP’s history task is to determine severity (systemically well vs unwell), exclude surgical complications (abscess, perforation, peritonitis), screen for PR bleeding (diverticular haemorrhage), and distinguish diverticulitis from colorectal cancer — which can mimic it exactly. A previous colonoscopy confirming diverticulosis is helpful but does not exclude CRC in a new presentation. Symptom duration of >6 weeks without resolution requires urgent 2WW CRC referral.

🎓 Consultation opener — use existing information first

“I can see you have known diverticulosis and now you have come in with this new left-sided pain — that must be worrying. Could you tell me exactly what has been happening and how you have been feeling?”

Reference the existing diagnosis in the notes; validate the concern about the new symptom; open question allows the patient to describe severity, fever, and functional impact naturally. Scores RO domain.

1A — Targeted history: the clinical questions that determine management

Question to ask	Why it matters clinically	Changes what?
🟩 OPEN QUESTION — always start here“Tell me about this pain — where is it, when did it start, what makes it better or worse, and how have you been feeling generally?”	An open question allows the patient to describe the key features of diverticulitis (LIF pain, fever, nausea, change in bowel habit) or to reveal atypical features suggesting alternative diagnoses (CRC, ovarian pathology, UTI, mesenteric ischaemia). It also allows the patient’s concerns (cancer fear, surgery anxiety, antibiotic expectation) to surface naturally.Scores RO domain: patient-centred opening; allows hidden agenda (surgery fear, cancer worry) to emerge without direct questioning	DDxPsychosocial
Pain location and character“Is it on the left side? Does it go anywhere? Is it constant or coming and going?”	Diverticulitis pain is classically constant LIF pain (sigmoid colon). Right-sided diverticulitis (rare in Western populations, more common in Asian populations) mimics appendicitis. Colicky pain suggests obstruction from a strictured diverticular segment. Constant severe pain with worsening suggests abscess or impending perforation.Right-sided abdominal pain mimicking appendicitis → do not assume diverticulitis; CT distinguishes; appendicitis cannot be excluded clinically	DDxUrgency
Systemic features — fever, rigors, vomiting“Have you had a temperature? Any shivering or rigors? Have you been vomiting or struggling to keep food down?”	Fever above 38°C with rigors or inability to maintain oral intake indicates complicated diverticulitis (abscess, peri-diverticular phlegmon) requiring hospital admission. Vomiting causing inability to take oral antibiotics is itself an indication for admission. Systemically well patients with mild fever can be managed in community with watchful waiting.Fever >38°C + vomiting + severe pain = complicated diverticulitis; hospital admission; do not manage in primary care	UrgencyManagement
PR bleeding — volume and character“Have you noticed any blood in or around your stools? How much blood and is it bright red or dark?”	Diverticular haemorrhage is the most common cause of large-volume painless lower GI bleeding in older patients. It tends to be sudden onset, painless, bright red or maroon, and large volume. This is a potentially life-threatening emergency causing haemodynamic instability. Any significant haemodynamic compromise requires 999 and hospital transfer.Large volume painless PR bleeding in an older patient with known diverticulosis = diverticular haemorrhage until proven otherwise; 999 if haemodynamically compromised	EmergencyDDx
Duration and previous episodes“How long have you had this? Have you had anything like this before, and how was it managed?”	Duration >6 weeks without resolution requires 2WW CRC referral (symptoms may reflect CRC rather than diverticulitis). Previous episodes help determine whether antibiotics were used and whether surgery has been discussed. Recurrent episodes (≥2) raise the question of elective sigmoid colectomy at next gastroenterology or colorectal surgery review.Pain lasting >6 weeks without resolution: 2WW CRC referral mandatory; do not repeatedly treat as diverticulitis without colonoscopy	DDxReferral
Urinary symptoms“Any problems passing urine — pain, frequency, cloudiness? Any unusual gas or faeces in your urine?”	Colovesical fistula from diverticular disease causes pneumaturia (air in urine), faecaluria (faeces in urine), and recurrent urinary tract infections. UTI is also a common differential for LIF pain in women. Dysuria alone does not distinguish UTI from pericolic inflammation in adjacent sigmoid colon from diverticulitis.Pneumaturia or faecaluria → colovesical fistula; urgent urology + colorectal surgery; CT urgently	DDxReferral
Bowel habit change — new or persistent“Has your bowel habit changed recently? Any new constipation or diarrhoea that is not settling? Any change in the shape or calibre of your stools?”	A new persistent change in bowel habit in a patient over 40 is a 2WW CRC red flag and must not be attributed to diverticulosis alone. Ribbon-like stools from an obstructing sigmoid cancer can exactly mimic the change in bowel habit seen in diverticular stricture. Age ≥40 + new change in bowel habit >6 weeks = 2WW CRC referral.Age ≥40 + change in bowel habit >6 weeks + no other explanation → 2WW CRC referral even in known diverticulosis; the two conditions coexist frequently	DDxReferral
Weight loss and appetite“Have you lost any weight without trying? Has your appetite changed?”	Unexplained weight loss in the context of LIF pain and change in bowel habit in a patient over 40 is a CRC red flag requiring immediate 2WW referral. Weight loss does not occur in uncomplicated diverticulitis. It should never be attributed to diverticular disease without excluding malignancy.Weight loss + LIF pain + change in bowel habit in any patient over 40 = 2WW CRC referral; this combination cannot be attributed to diverticular disease alone	DDxReferral
Diet and fibre intake“Tell me about your typical diet — how much fruit, vegetables, and fibre do you normally eat? Any significant dietary changes recently?”	Low-fibre diet is the strongest modifiable risk factor for diverticulosis. 30g/day fibre target is the NICE-recommended long-term goal for diverticular disease management and prevention of recurrence. Dietary advice is the cornerstone of lifestyle management for diverticular disease and is often more impactful than any pharmacological intervention.During an acute attack: low-fibre diet temporarily (soft foods, adequate fluids); in remission: high-fibre 30g/day diet reduces recurrence risk significantly	Management
Medications — NSAIDs, opiates, steroids“Are you taking any anti-inflammatories or strong pain tablets regularly? Any steroids?”	NSAIDs are associated with diverticular perforation and haemorrhage. Opiates cause constipation, worsening diverticular disease and potentially precipitating obstruction. Corticosteroids mask the systemic features of complicated diverticulitis (fever, peritonism) — a high index of suspicion is needed in steroid-treated patients.NSAIDs in diverticular disease: associated with 3× increased risk of perforation; switch to paracetamol; document at every review	ManagementDDx

1B — Red flags: must not miss

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Peritonism / perforation (guarding, rebound, rigidity)	Hinchey III (purulent peritonitis) or Hinchey IV (faecal peritonitis) from diverticular perforation are life-threatening surgical emergencies. Mortality is 20–30% without prompt surgical intervention. Peritonism in any patient with diverticular disease is a 999 emergency.	999 immediately
Haemodynamic compromise from PR bleeding	Massive diverticular haemorrhage can cause life-threatening haemodynamic instability. Signs: pallor, tachycardia, hypotension, dizziness on standing. Diverticular haemorrhage is the most common cause of major lower GI bleeding in older patients.	999; IV access
CRP >150 or high fever >38.5°C + significant pain	CRP >150 mg/L suggests complicated diverticulitis (Hinchey Ia/Ib abscess or worse). These patients require CT imaging and hospital assessment regardless of how clinically well they appear. Primary care watchful waiting is inadequate.	Same-day hospital; CT abdomen
Immunocompromised patient (steroids, chemotherapy, biologics)	Immunosuppression masks the classical signs of peritonism and sepsis in diverticulitis. Complicated diverticulitis can present with minimal systemic features in immunocompromised patients. Lower threshold for hospital admission is essential.	Lower threshold for admission; CT urgently
Symptoms >6 weeks, change in bowel habit, or weight loss	Diverticulitis does not cause prolonged symptoms without resolution, significant weight loss, or persistent change in bowel habit. These features in the context of diverticular disease must trigger 2WW CRC referral — the two conditions frequently coexist.	2WW CRC referral
Pneumaturia or faecaluria	Colovesical fistula from complicated diverticular disease causes air or faeces in the urine, recurrent polymicrobial UTIs, and risk of ascending urosepsis. Requires CT fistulogram and combined urology + colorectal surgery assessment.	Urgent urology + colorectal surgery
Palpable abdominal mass	A palpable mass in the left lower quadrant in a patient with diverticular disease may represent a diverticular abscess, phlegmon, or — critically — a sigmoid carcinoma. Both require urgent imaging (CT) and specialist assessment. The mass cannot be attributed to diverticular disease without imaging.	CT abdomen urgently; 2WW CRC if malignancy cannot be excluded

🛡️

Safeguarding Considerations

Diverticular disease predominantly affects older adults, who may have additional vulnerability from cognitive impairment, social isolation, carer dependence, and nutritional neglect. Severe abdominal pain in a frail older patient may not be reported promptly, leading to delayed presentation with complicated disease. A low threshold for admission in frail older adults with diverticulitis is essential.

👴 Frail Older Adults

Frail older adults may not develop classical peritonism even with perforation due to reduced abdominal wall musculature; high index of suspicion required
Cognitive impairment may mask symptom severity — collateral history from carer is essential
Malnutrition is common and worsens diverticular disease; nutritional assessment and dietitian referral are essential in frail patients
Lower threshold for hospital admission and CT imaging in frail older adults with diverticulitis

💊 NSAIDs and Polypharmacy

Many older patients with diverticular disease take NSAIDs for musculoskeletal pain or antiplatelet agents, both of which significantly increase the risk of diverticular perforation and haemorrhage
Medication review at every diverticular disease consultation is essential; document NSAID avoidance advice
Anticoagulant use significantly increases the risk and severity of diverticular haemorrhage; monitor INR and anticoagulation carefully

🏠 Social Isolation and Self-Neglect

Older adults living alone may delay seeking help for abdominal pain until the disease is complicated
Social prescribing referral; ensure patient has a reliable emergency contact; consider community assessment where appropriate
Nutrition counselling for patients living alone who may have poor dietary fibre intake; social services referral if self-neglect is evident

💐 Cancer Fear and Diagnostic Certainty

Diverticular disease is common and real, but it should never be used to explain away symptoms that require cancer exclusion
Patients with diverticulosis who present with new symptoms have the same cancer risk as the general population plus their existing diverticular disease
Never attribute persistent symptoms to diverticular disease without appropriate investigation; document CRC exclusion reasoning clearly

If a safeguarding concern is identified: For frail older adults with suspected complicated diverticulitis: lower the threshold for hospital admission significantly; seek collateral history from carers; refer to social services if self-neglect is identified. Document NSAID avoidance advice at every diverticular disease consultation.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
Previous diverticulitis episodes	Number and severity of previous episodes determines whether elective sigmoid colectomy should be discussed	≥2 episodes or one complicated episode → discuss elective sigmoid colectomy at next colorectal surgery or gastroenterology review
Previous colonoscopy / CRC surveillance	Last colonoscopy date and result determines cancer surveillance need; diverticulosis found on colonoscopy does not exclude concurrent CRC	Colonoscopy >3–5 years ago in patient with new symptoms → repeat colonoscopy; 2WW if red flags present
Family history of CRC	FH of CRC lowers the threshold for 2WW referral and colonoscopy in a patient with diverticular disease and new symptoms	FH of CRC + new bowel symptoms → 2WW CRC referral; lower index for colonoscopy even if symptoms are mild
Immunosuppression (steroids, chemotherapy, biologics)	Immunosuppressed patients with diverticulitis have attenuated systemic features (fever may be absent or blunted) and progress to complicated disease more rapidly	Lower threshold for hospital admission; CT imaging more readily; longer course of antibiotics if used; seek surgical review earlier
Inflammatory bowel disease	Diverticular disease coexists with Crohn’s colitis and UC in older patients; Crohn’s colitis can affect the sigmoid colon and mimic diverticulitis	Check prior IBD diagnosis; calprotectin if IBD flare cannot be excluded; gastroenterology co-management if IBD + diverticulitis
Anticoagulation (warfarin, DOAC)	Anticoagulation significantly increases the risk and volume of diverticular haemorrhage; INR must be checked in warfarin-treated patients presenting with PR bleeding	PR bleeding on anticoagulation → hospital admission; check INR; temporary anticoagulation reversal decisions with haematology

💊 Drug history · Social history

Factor	Why it matters	Management impact
NSAIDs (regular use)	NSAIDs are associated with a 3× increased risk of diverticular perforation and haemorrhage; prostaglandin inhibition impairs mucosal defence in the colonic wall	Switch to paracetamol; document NSAID avoidance at every consultation; discuss with rheumatology if NSAIDs required for comorbidity
Opiates (codeine, morphine)	Opiates cause constipation, worsening diverticular disease and increasing the risk of diverticulitis; stool softeners do not fully offset this effect	Reduce opiate burden where possible; stool softener if opiates unavoidable; laxative not lactulose (causes gas); avoid gas-producing laxatives
Anticoagulants (warfarin, DOACs)	Significantly increase the risk of diverticular haemorrhage; PR bleeding on anticoagulation may be large volume and haemodynamically significant	Hospital admission for any significant PR bleeding on anticoagulation; consider anticoagulation reversal; timing of recommencement with haematology
Diet — fibre intake	Low-fibre diet is the strongest modifiable risk factor for diverticulosis formation and recurrence of diverticulitis; NICE recommends 30g/day fibre in remission	Dietary advice: low-fibre during acute attack; increase to 30g/day during remission; ispaghula husk supplement if dietary change insufficient; dietitian referral
Physical activity	Sedentary lifestyle is associated with increased diverticulosis risk; regular exercise improves colonic motility and reduces constipation	Encourage 150 minutes/week moderate activity; exercise improves bowel habit and reduces diverticular symptoms
Obesity	Obesity is an independent risk factor for diverticular disease and its complications; BMI >30 is associated with higher diverticulitis severity	Weight management advice; referral to Tier 3 weight management service if BMI >35; dietary fibre and exercise primary interventions

1D — ICE: Ideas · Concerns · Expectations

The most common ICE challenge in diverticular disease is the antibiotic expectation. NICE NG147 recommends watchful waiting without routine antibiotic prescribing for uncomplicated acute diverticulitis in systemically well patients. This runs directly contrary to most patients’ expectation that antibiotics are the appropriate treatment for an infection. Exploring and negotiating the antibiotic expectation — rather than simply prescribing or refusing — is the most clinically and communicatively complex task in this consultation. A second common concern is surgery fear, which may prevent the patient from disclosing symptom severity.

💭 Ideas

“What do you think is happening right now? Do you have an understanding of your diverticular condition and what causes these attacks?”

Many patients with diverticulosis have received inconsistent advice over time — some have been told to avoid seeds and nuts (outdated guidance), others have been told high-fibre diet prevents attacks, others have no dietary advice at all. Understanding the patient’s existing model of their condition allows targeted correction of misconceptions.

😟 Concerns

“Are you worried about what this pain might mean — perhaps that it is cancer, or that you might need surgery? And are you worried about how long it will take to settle?”

The three dominant concerns in diverticular disease: (1) cancer fear — particularly when pain is severe or symptoms are new; (2) surgery fear — particularly Hartmann’s procedure with permanent stoma; (3) recurrence anxiety — fear that each episode will require surgery or will get worse. All three should be named and addressed with accurate data.

🎯 Expectations

“Were you expecting antibiotics today? I want to explain what the evidence shows about treatment — it is different from what most people expect, and I want to make sure you understand the reason.”

The antibiotic expectation is the most common source of consultation dissatisfaction in uncomplicated diverticulitis. NICE NG147 clearly recommends against routine antibiotic prescribing for uncomplicated acute diverticulitis. Acknowledging the expectation, explaining the evidence (antibiotics do not shorten recovery or prevent complications in uncomplicated disease), and providing a clear safety-net is the appropriate approach.

1E — Psychosocial context

🍽️ Diet and Lifestyle Anxiety

Many patients with diverticular disease develop significant anxiety about food, avoiding all seeds, nuts, and high-fibre foods based on outdated guidance (this advice has no evidence base). This dietary restriction often causes nutritional deficiency without preventing attacks. Correcting this misconception and providing current evidence-based dietary guidance is an important part of management.

“I want to address something many patients are worried about: the advice about avoiding seeds and nuts. The evidence does not support this, and in fact, it was never based on good research. The opposite is true — a high-fibre diet, including seeds and nuts, is what we now recommend in remission.”

🧠 Surgery Fear and Recurrence Anxiety

Fear of needing a stoma or major abdominal surgery is very common in patients with diverticular disease. This fear can cause patients to minimise symptoms, delay seeking help, or refuse appropriate management. Accurate, compassionate information about surgical rates and the availability of elective laparoscopic colectomy (which usually avoids stoma) reduces fear-driven non-engagement.

“I can hear you are worried about surgery. Let me give you some specific information: most people with diverticulitis — even those with recurrent attacks — are managed without surgery. If surgery does become the right option, it is usually planned, and techniques have improved significantly.”

📈 Cancer Fear

Diverticular disease and CRC are both common in the same age group and frequently coexist. A diagnosis of diverticulosis does not protect against CRC. New symptoms in a patient with known diverticulosis require the same cancer vigilance as in any other patient. Patients are often falsely reassured by their diverticulosis diagnosis.

“Your known diverticulosis does not rule out other causes of your symptoms. If the pain or change in bowel habit does not settle as expected, I will be arranging further investigation to make sure we are not missing anything else.”

🏢 Work, Activities, and Quality of Life

Recurrent diverticulitis significantly impairs quality of life through unpredictable attacks, time off work, dietary restrictions, and the social impact of altered bowel function. The chronicity of diverticular disease — and the real risk of recurrence — must be discussed as part of long-term management, including when to consider elective surgery.

“I want to ask how this is affecting your day-to-day life — your work, your diet, things you enjoy. Because if these attacks are significantly disrupting your life, that changes what we might consider as the best long-term plan for you.”

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

“I need to ask you some specific questions to work out how serious this attack is — particularly about your temperature and how you have been managing with food and drink.”

“I can tell you were expecting antibiotics — and I want to explain why the guidance has changed and why we are not recommending them routinely for milder attacks now.”

“Have you noticed any blood in your urine, or any sensation of air or stool when you pass urine? I am asking about a specific complication of diverticular disease.”

Deductions (examiner flags)

Not asking about PR bleeding — missing the risk of diverticular haemorrhage
Not asking about urinary symptoms — missing colovesical fistula
Attributing all new symptoms to diverticular disease without considering CRC
Not exploring the antibiotic expectation before refusing or prescribing
Not asking about duration (symptoms >6 weeks require 2WW CRC referral)

🔴 Red — failing

PR bleeding not asked · CRC not considered · All symptoms attributed to diverticulosis · Antibiotic expectation not explored · Fever and systemic features not assessed

🟠 Amber — borderline

Severity assessed but CRC not considered · Antibiotic expectation not explored · Duration not asked · Urinary symptoms omitted

🟢 Green — passing

Severity assessed (fever, vomiting, CRP) · PR bleeding asked · CRC differential raised · Antibiotic expectation explored · Duration and prior episodes established · Urinary symptoms asked

Step 2

Triage Engine — Emergency · Urgent · Routine

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The triage decision in diverticular disease turns on two questions: (1) is the patient systemically unwell (complicated diverticulitis requiring hospital)? and (2) are there red flags suggesting a surgical emergency (peritonism, haemorrhage, fistula)? Uncomplicated acute diverticulitis in a systemically well patient can be managed in primary care with watchful waiting, adequate analgesia, and dietary advice. CRP >150, fever >38°C, inability to maintain oral intake, or peritonism all require hospital admission.

🔴 Emergency

999 / Same-Day Hospital

Act immediately

Hinchey III–IV: peritonism / perforationGuarding + rebound + rigidity → 999; IV antibiotics en route; emergency laparotomy required
Massive diverticular haemorrhage with haemodynamic compromiseTachycardia + hypotension + large PR bleeding → 999; IV access; group and save; fluid resuscitation
Complicated diverticulitis (CRP >150, fever >38.5°C, vomiting)Hospital admission for CT abdomen, IV antibiotics, surgical assessment; Hinchey Ia/Ib abscess likely
Colovesical fistula (pneumaturia, faecaluria, urosepsis)Same-day urology + colorectal surgery; CT fistulogram; risk of ascending sepsis
Immunocompromised patient with any diverticulitis featuresLower threshold for admission; peritonism may be absent or attenuated; CT urgently

🟠 Urgent

Urgent Assessment

Days

Moderate diverticulitis: CRP 50–150, mild fever, well enough to manage oral fluidsGP assessment and same-day CRP; if worsening within 24–48 hours, hospital admission; clinical review next day
Symptoms >6 weeks / persistent change in bowel habit / weight loss2WW CRC referral; colonoscopy to exclude malignancy; do not attribute prolonged symptoms to diverticulosis alone
Palpable abdominal mass in known diverticulosisUrgent CT abdomen + 2WW CRC referral; cannot exclude carcinoma without imaging
Moderate PR bleeding, haemodynamically stableUrgent FBC + clotting; hospital assessment same day; colonoscopy within 24 hours to identify source
Recurrent diverticulitis (≥2 episodes)Referral to colorectal surgery to discuss elective sigmoid colectomy; plan at next gastroenterology or colorectal review

🟢 Routine

Primary Care Management

GP practice

Uncomplicated acute diverticulitis (systemically well, CRP <150, tolerating oral intake)Watchful waiting per NICE NG147; no routine antibiotics; liquid diet initially; adequate analgesia; review in 48–72 hours
Incidental diverticulosis counsellingDietary advice (30g/day fibre in remission); exercise; NSAID avoidance; correct dietary myths (no seed/nut restriction); cancer surveillance per CRC screening programme
Chronic diverticular pain (chronic intermittent symptoms in remission)Analgesia (paracetamol); high-fibre diet; regular exercise; consider antispasmodics; avoid NSAIDs and opiates; review for CRC if new features
Annual review of recurrent diverticular diseaseMedication review (NSAID avoidance); dietary adherence; exercise; elective surgery discussion if ≥2 episodes; mental health screen; last colonoscopy date

🎓 SCA Checkpoint — Step 2TasksRelating to OthersGlobal Skills

Key phrases that score

“Because you are not running a high fever, you are keeping fluids down, and you do not have severe pain on examination — I am satisfied this can be managed at home, though I want to be very clear about when that changes.”

“The guidance has changed on antibiotics for diverticulitis. For mild attacks in people who are generally well, antibiotics do not shorten the illness or prevent complications — so the recommended approach is watchful waiting, with clear instructions about when to seek help.”

Deductions (examiner flags)

Prescribing antibiotics for uncomplicated diverticulitis without acknowledging the NICE NG147 guidance against routine use
Discharging a patient with CRP >150 or fever >38.5°C to home management
Not arranging follow-up within 48–72 hours for a patient managed at home
Not considering 2WW CRC referral for symptoms lasting >6 weeks

🔴 Red — failing

Complicated diverticulitis not admitted · Antibiotics prescribed without NICE context · CRC not considered · No follow-up arranged

🟠 Amber — borderline

Triage correct but NICE NG147 watchful waiting not mentioned · Antibiotic expectation not addressed · Follow-up vague

🟢 Green — passing

Correct triage based on severity · NICE NG147 watchful waiting explained · Antibiotic expectation negotiated · 48–72 hour review arranged · CRC considered · Hospital criteria clearly stated to patient

Step 3

Do I Need This Examination?

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Examination in suspected diverticulitis establishes systemic severity and excludes surgical complications. The key examination is abdominal palpation — specifically looking for peritonism (guarding, rebound, rigidity) which indicates a surgical emergency. LIF tenderness without peritonism is consistent with uncomplicated diverticulitis. A palpable mass must be investigated with CT urgently (abscess vs carcinoma). Rectal examination is important if PR bleeding is reported.

Examination	Why it matters	What finding changes management	Changes management?
Vital signs — pulse, temperature, BP	Fever >38°C is a criterion for complicated diverticulitis. Tachycardia indicates systemic inflammatory response or haemodynamic compromise from haemorrhage. Postural hypotension indicates significant dehydration or blood loss requiring hospital admission.HR >100 + LIF pain + fever = complicated diverticulitis; hospital admission; do not manage in primary care	Fever >38°C or HR >100 → hospital; postural drop → IV fluids + admission	YES — changes triage immediately
Abdominal palpation — peritonism screen	LIF tenderness without peritonism = uncomplicated diverticulitis (may manage in primary care). Peritonism (guarding, rebound, rigidity) = Hinchey III–IV perforation or abscess — 999 immediately. A palpable mass in LIF = abscess or carcinoma — CT urgently. Distension + absent bowel sounds = obstruction.Guarding or rebound tenderness on abdominal examination → 999; do not attempt further investigation in primary care	LIF tenderness → uncomplicated; peritonism → 999; palpable mass → urgent CT; distension → hospital	YES — most important finding
Rectal examination	If PR bleeding has been reported, digital rectal examination assesses blood on the glove, rectal masses, and the character of blood (fresh vs altered). Caution: DRE is not essential in every case and may be uncomfortable; clinical judgement applies.Blood on DRE glove + LIF pain → diverticular haemorrhage or CRC; urgent hospital assessment in either case if significant	Blood on DRE → hospital assessment; rectal mass → 2WW CRC referral; haemodynamic compromise → 999	Context — if PR bleeding reported
General inspection — hydration, pallor	Pallor and signs of dehydration (dry mucous membranes, reduced skin turgor) in a patient with diverticulitis indicate inability to maintain adequate oral intake — an indication for hospital admission. Jaundice may indicate liver abscess from septic emboli (rare complication).Clinical dehydration in diverticulitis → unable to manage at home; hospital admission for IV fluids	Clinical dehydration → hospital; pallor + tachycardia → haemorrhage pathway	YES — if dehydration or pallor found
Urine dipstick	Pyuria and haematuria in a patient with LIF pain may indicate UTI (common differential) or colovesical fistula (pneumaturia may be present on dipstick). A urine M/C/S is essential if dipstick is positive.Sterile pyuria + LIF pain + air in urine → colovesical fistula; same-day urology + colorectal surgery	Pyuria → send M/C/S; positive dipstick + LIF pain → consider colovesical fistula vs UTI; CT if fistula suspected	Context — always if urinary symptoms
Blood pressure (postural)	Postural hypotension (>20 mmHg systolic drop on standing) in a patient with diverticular disease and reported PR bleeding indicates significant blood loss and haemodynamic compromise requiring urgent hospital transfer.Postural hypotension + PR bleeding = haemodynamically significant GI haemorrhage; 999 or urgent hospital transfer	Postural drop + PR bleeding → 999	YES — haemodynamic emergency

🎓 SCA Checkpoint — Step 3TasksRelating to OthersGlobal Skills

Key phrases that score

“I am going to examine your tummy now — I particularly want to check for any sign of the inflammation spreading, which would change what we do today.”

“Your tummy is tender on the left side but it is not rigid and there is no guarding — that tells me this is not a surgical emergency right now, which is reassuring. It is consistent with diverticulitis that we can manage carefully at home.”

Deductions (examiner flags)

Not specifically examining for peritonism (guarding, rebound) — the critical finding that changes triage to 999
Missing a palpable LIF mass and not arranging urgent CT
Not measuring vital signs in a patient with abdominal pain and fever
Not doing a urine dipstick when urinary symptoms are reported

🔴 Red — failing

No peritonism assessment · Vital signs not taken · Palpable mass missed · Urine dipstick not done despite urinary symptoms

🟠 Amber — borderline

Abdomen examined but peritonism assessment not clearly communicated · Findings not linked to management decision

🟢 Green — passing

Peritonism specifically assessed and reported · Vital signs taken and linked to triage · Findings communicated clearly · Management decision explained from examination findings

Step 4

Do I Need This Investigation?

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Investigation in acute diverticulitis serves two purposes: confirming the diagnosis and severity, and excluding CRC and complications. CRP is the single most useful primary care investigation: CRP >150 mg/L indicates complicated diverticulitis requiring hospital admission. CT abdomen is the gold standard for confirming diagnosis, grading severity (Hinchey classification), and identifying abscess or perforation — it should be requested in hospital. Colonoscopy is NOT done during acute diverticulitis (perforation risk) but must be arranged 6–8 weeks after resolution to exclude CRC.

Investigation	Clinical question it answers	What result changes management?
CRP (C-reactive protein) — the most important primary care test	CRP >150 mg/L indicates complicated diverticulitis (abscess likely) and mandates hospital admission. CRP 50–150 suggests moderate diverticulitis — close GP monitoring with review in 24–48 hours. CRP <50 in a systemically well patient supports uncomplicated disease manageable in primary care.	CRP >150 → hospital admission; CT abdomen + IV antibiotics · CRP 50–150 → GP monitoring; review 24–48 hours; if worsening, admit · CRP <50 + well → community management; watchful waiting
FBC (Full Blood Count)	Leucocytosis confirms systemic infection and may guide antibiotic decisions if prescribed. Anaemia from occult blood loss or acute haemorrhage; thrombocytosis reactive in sepsis. WBC >15 in a patient with LIF pain warrants hospital assessment.	WBC >15 + fever → complicated diverticulitis; hospital · Hb <100 → active haemorrhage or chronic blood loss; hospital for transfusion assessment
U&E (Urea and electrolytes)	Raised urea and creatinine from dehydration secondary to vomiting and poor intake. AKI risk in elderly patients with diverticulitis and poor intake. Electrolyte disturbance if significant vomiting has occurred.	AKI (creatinine rise >26 μmol/L or >50% from baseline) → hospital IV fluids; electrolyte abnormality → admit for IV correction
Urine M/C/S	Distinguishes UTI from pericolic inflammation irritating the bladder (causing sterile pyuria). Colovesical fistula causes polymicrobial UTI (mixed faecal organisms on M/C/S) — a specific diagnostic clue. Pneumaturia may be noted by the patient.	Polymicrobial UTI (mixed faecal organisms) → colovesical fistula suspected; CT fistulogram + urology referral · Simple UTI → appropriate antibiotic
CT abdomen and pelvis — gold standard, in hospital	Confirms diagnosis, grades Hinchey severity, identifies abscess (size and drainage potential), perforation (free gas), obstruction, and colovesical fistula. Essential for any patient admitted with suspected complicated diverticulitis. Not routinely needed in primary care for uncomplicated disease.	Hinchey I/II abscess → CT-guided drainage or surgical drainage; Hinchey III/IV → emergency surgery; carcinoma found → 2WW oncological pathway; fistula mapped → surgical repair planning
Colonoscopy — after recovery (NOT during acute attack)	Colonoscopy is contraindicated during acute diverticulitis due to perforation risk. Post-recovery colonoscopy (6–8 weeks after resolution) excludes concurrent CRC, defines diverticular extent, and establishes surveillance needs. This is a mandatory step after a first episode of diverticulitis.	Carcinoma found → 2WW oncological pathway + MDT · Extensive diverticulosis → surveillance plan · Normal → reassurance; high-fibre dietary advice
Blood cultures (in hospital)	Blood cultures guide antibiotic de-escalation in hospitalised patients with complicated diverticulitis. Should be taken before IV antibiotic commencement in hospitalised patients. Not required in primary care for uncomplicated disease.	Positive blood cultures → targeted antibiotic therapy; sensitivities guide de-escalation; Gram-negative bacteraemia → prolonged IV course
AXR (Abdominal plain X-ray)	AXR is of limited diagnostic value in diverticulitis (CT is superior) but may show free gas under the diaphragm (perforation) or dilated bowel (obstruction) in the acute setting. If CT is immediately available, AXR adds little except in resource-limited settings.	Free gas on erect AXR → perforation confirmed; emergency surgical referral; dilated bowel loops → obstruction; surgical assessment

🎓 SCA Checkpoint — Step 4TasksRelating to OthersGlobal Skills

Key phrases that score

“The most useful blood test I want to do right now is a CRP — that inflammation marker will tell me how severe this episode actually is and whether you can safely manage this at home or whether I need to send you to hospital.”

“I want to arrange a colonoscopy for you about 6–8 weeks after this settles — not because I think it is cancer, but because it is important to confirm the diagnosis and make sure we are not missing anything in the bowel.”

Deductions (examiner flags)

Arranging colonoscopy during the acute diverticulitis attack (perforation risk)
Not ordering CRP to guide the primary care management decision
Failing to arrange post-recovery colonoscopy to exclude CRC after a first episode
Not considering CT in a patient with a palpable abdominal mass

🔴 Red — failing

No CRP ordered · Colonoscopy during acute attack · Post-recovery colonoscopy not discussed · CRC not considered

🟠 Amber — borderline

CRP ordered but threshold not communicated to patient · Post-recovery colonoscopy mentioned but purpose not explained · CT not considered for palpable mass

🟢 Green — passing

CRP threshold explained to patient (if >150 = hospital) · Colonoscopy deferred until after recovery · Post-recovery colonoscopy confirmed with reason · CT for palpable mass or complicated features · Urine M/C/S if urinary symptoms

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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Diverticulosis is extremely common in the Western population (50% by age 50; 70% by age 70) but causes symptoms in only a minority. Diverticulitis occurs in approximately 5% of those with diverticulosis. The GP’s diagnostic task is to confirm that the acute episode is diverticulitis, grade its severity using the Hinchey classification, and critically, to exclude colorectal cancer which can present identically and coexists with diverticulosis in the same age group.

🗣️ Explaining the Diagnosis in Plain Language

“Diverticulosis means there are small pouches — called diverticula — that have formed in the wall of your large bowel over time. They are extremely common in people of your age and are usually completely harmless. Diverticulitis is what happens when one of these pouches becomes inflamed or infected — that is what is causing your pain and fever now. The good news is that the majority of attacks — including yours, from what I can tell — settle down with rest, fluids, and adequate pain relief. Most people do not need antibiotics, and most do not need surgery. However, I want to monitor you carefully over the next few days and arrange a camera test of the bowel once this settles, just to make sure everything looks as expected.”

💬 Addressing common patient concerns

“Should I avoid nuts and seeds?”
“This is a really common question, and it is based on advice that used to be given but that we now know is not supported by evidence. The current guidance is actually the opposite — a high-fibre diet, including seeds, nuts, and wholegrains, reduces the risk of further attacks when you are well. The only time we change this is during an acute attack, when a softer, lower-fibre diet is more comfortable for a few days.”

“Why are you not giving me antibiotics? I have an infection.”
“That is a really fair question. In the past, we always gave antibiotics for diverticulitis. But good-quality evidence from several large studies has shown that for attacks like yours — where you are not running a high temperature and can manage fluids at home — antibiotics do not actually shorten the illness or prevent complications. The national guidance now recommends watching carefully and keeping you well-monitored rather than giving antibiotics routinely. I will give you very clear advice about when that changes.”

A — The Diverticular Disease Spectrum

Asymptomatic Diverticulosis

Incidental finding on colonoscopy or imaging. Requires dietary advice (high fibre, NSAID avoidance), cancer surveillance per bowel cancer screening programme. No treatment required.

Uncomplicated Acute Diverticulitis

LIF pain + fever + raised CRP; no peritonism, no abscess on CT. Manage in primary care with watchful waiting per NICE NG147.

Complicated Acute Diverticulitis (Hinchey I–IV)

Abscess (I/II), purulent peritonitis (III), or faecal peritonitis (IV). Hospital management with CT, IV antibiotics, and surgical assessment.

Diverticular Haemorrhage

Sudden large-volume painless PR bleeding; most common cause of major lower GI bleeding in older patients; usually arterial (vasa recta at diverticular neck); colonoscopy or IR angiography.

B — Important DDx to Exclude

Colorectal Cancer (CRC)

CRC and diverticulosis coexist in the same age group and can present identically. Change in bowel habit, PR bleeding, or LIF mass in a patient with known diverticulosis must trigger CRC exclusion. 2WW referral if red flags present. Post-recovery colonoscopy mandatory after first diverticulitis episode.

Urinary Tract Infection (UTI)

LIF pain + dysuria + fever in women may be UTI rather than diverticulitis. Urine dipstick and M/C/S essential. However, pericolic inflammation from diverticulitis commonly causes sterile pyuria — this does not mean UTI.

Ovarian Pathology (women)

Ovarian cyst, torsion, or ectopic pregnancy cause LIF pain in women and can closely mimic diverticulitis. Pelvic ultrasound in any woman of reproductive age with LIF pain of uncertain cause.

Irritable Bowel Syndrome

IBS causes chronic intermittent LIF pain and change in bowel habit but without systemic features (no fever, normal CRP, normal FBC). Diverticulosis often coexists with IBS; both diagnoses may need to be managed simultaneously.

C — Hinchey Classification of Complicated Diverticulitis

Hinchey I — Pericolic Abscess

Small abscess confined to the mesentery adjacent to the colon. IV antibiotics; CT-guided drainage if >3cm; usually resolves without surgery.

Hinchey II — Pelvic or Distant Abscess

Larger abscess distant from the perforation. CT-guided percutaneous drainage; IV antibiotics; surgical option if drainage fails.

Hinchey III — Purulent Peritonitis

Perforation with purulent pus in the peritoneal cavity. Emergency surgery (Hartmann’s procedure — sigmoid resection + end colostomy); IV antibiotics; HDU/ICU post-operatively.

Hinchey IV — Faecal Peritonitis

Free faecal contamination of the peritoneal cavity. Most severe; highest mortality (30–50%); emergency laparotomy; Hartmann’s procedure; aggressive resuscitation.

🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills

Key phrases that score

“Diverticulosis means small pouches in the bowel wall — very common at your age, usually harmless. Diverticulitis is when one of those pouches gets inflamed — that is what I think is happening now.”

“I want to be clear: the fact that you have diverticulosis does not protect you against other problems in the bowel. After this settles, I would like to arrange a colonoscopy to make sure everything looks as expected.”

“About seeds and nuts — the old advice about avoiding them is not supported by evidence. The opposite is true: a high-fibre diet including seeds and nuts is what we recommend when you are well.”

Deductions (examiner flags)

Falsely reassuring the patient that diverticulosis explains all their symptoms without CRC consideration
Reinforcing the outdated seeds and nuts restriction (not evidence-based)
Not explaining that post-recovery colonoscopy is needed to exclude CRC
Not addressing the antibiotic expectation with the NICE evidence

🔴 Red — failing

CRC not mentioned · Antibiotic expectation not addressed · Seeds/nuts restriction reinforced · Post-recovery colonoscopy not discussed

🟠 Amber — borderline

Diagnosis explained but CRC risk not raised · Antibiotics refused without NICE context · Dietary advice incomplete

🟢 Green — passing

Diverticulosis vs diverticulitis distinction clear · CRC requires exclusion despite known diverticulosis · Post-recovery colonoscopy · NICE NG147 watchful waiting explained · Seeds/nuts myth corrected · Plain language throughout

Step 6

If Referral Is Needed — What the GP Does Before & During

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Most uncomplicated diverticulitis is managed entirely in primary care. Hospital admission is required for complicated diverticulitis (CRP >150, fever >38.5°C, unable to maintain oral intake, peritonism). Colorectal surgery referral is appropriate for recurrent diverticulitis (≥2 episodes) or complicated disease. Post-recovery colonoscopy (6–8 weeks after resolution) is mandatory after a first episode to exclude CRC. The GP coordinates these pathways, manages the acute episode, and ensures the post-recovery workup happens.

Condition	Urgency	What GP does before referral	What GP must NOT do
Complicated diverticulitis (CRP >150 or peritonism)	Same-day hospital	CRP + FBC + U&E; do not give oral antibiotics (IV needed); IV access if available; arrange direct hospital admission; contact surgical/medical on-call; write clear referral letter with CRP result and examination findings	Do not send home with oral antibiotics if CRP >150 or peritonism is present; do not arrange outpatient CT — this needs same-day hospital assessment
Hinchey III–IV peritonism / perforation	999 immediately	999 immediately; IV access + fluid bolus if available; note time of symptom onset; do not give opiates that might mask examination findings if patient is being assessed imminently	Do not delay for investigations; do not give oral laxatives or enemas; do not attempt abdominal imaging in primary care — 999 first
Post-recovery colonoscopy (after 1st episode)	6–8 weeks post-recovery	Arrange colonoscopy referral at resolution of acute episode; document the reason (CRC exclusion) clearly in referral; ensure patient is aware this is cancer exclusion, not routine check; chase if not received within 8 weeks	Do not arrange colonoscopy during the acute attack (perforation risk); do not omit post-recovery colonoscopy — CRC must be excluded after every first episode of diverticulitis
2WW CRC referral — red flags in diverticular disease	2-week wait	Send 2WW referral if: age ≥40 + symptoms >6 weeks; weight loss + change in bowel habit; palpable mass; PR bleeding with altered bowel habit; unexplained iron deficiency anaemia; do not delay referral based on presence of diverticulosis	Do not attribute persistent symptoms to diverticulosis without CRC exclusion; the presence of diverticulosis should not reduce the threshold for 2WW referral
Elective sigmoid colectomy (≥2 episodes)	Routine colorectal surgery	Discuss with patient after second episode; refer to colorectal surgery clinic; document episode history, severity, and antibiotic use; ensure colonoscopy has been done to exclude CRC; patient preference is central to surgical decision-making	Do not recommend elective surgery after a single uncomplicated episode without discussing at a joint colorectal surgery + patient consultation; elective colectomy has significant risks that must be discussed
Colovesical fistula	Urgent urology + colorectal surgery	Urine M/C/S (polymicrobial expected); arrange CT fistulogram; refer simultaneously to urology and colorectal surgery; ensure patient takes cranberry juice or similar to acidify urine (reduces bacterial adhesion) while awaiting specialist review	Do not treat colovesical fistula as a simple UTI with repeated antibiotic courses; the underlying fistula will not close without surgical repair

🎓 SCA Checkpoint — Step 6TasksRelating to OthersGlobal Skills

Key phrases that score

“After this episode settles — usually about 6 to 8 weeks — I will arrange a colonoscopy for you. That is not because I am worried about cancer specifically, but because it is standard practice to make sure the bowel looks as expected after a first episode of diverticulitis.”

“If you develop very severe pain, your temperature goes above 38 degrees, or you start vomiting and cannot keep fluids down — please go to A&E rather than waiting for a GP appointment.”

Deductions (examiner flags)

Arranging colonoscopy during the acute attack rather than post-recovery
Not planning post-recovery colonoscopy after a first episode of diverticulitis
Not referring for 2WW when red flags (weight loss, change in bowel habit >6 weeks) are present
Repeatedly treating presumed UTI without considering colovesical fistula in a patient with recurrent infections and known diverticular disease

🔴 Red — failing

Colonoscopy during acute attack · Post-recovery colonoscopy omitted · 2WW not triggered by red flags · Complicated diverticulitis managed at home

🟠 Amber — borderline

Post-recovery colonoscopy mentioned but reason not explained · 2WW not triggered despite duration >6 weeks · Referral pathway not clearly communicated

🟢 Green — passing

Post-recovery colonoscopy planned + reason explained · 2WW triggered correctly · Hospital admission criteria clearly stated · Elective surgery discussion offered if ≥2 episodes · Colovesical fistula pathway known

Step 7

Management — Expectation · Goals · Lifestyle · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

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Management of acute uncomplicated diverticulitis follows NICE NG147 (2019): watchful waiting without routine antibiotics, adequate analgesia (paracetamol — NOT NSAIDs or opiates), temporary low-fibre diet during the acute attack, adequate hydration, and clinical review within 48–72 hours. Antibiotics (co-amoxiclav or metronidazole + ciprofloxacin) are reserved for complicated disease, immunocompromised patients, or patients who deteriorate. Long-term management focuses on a high-fibre diet (30g/day target), NSAID avoidance, and surveillance colonoscopy post-recovery.

7A — Address the patient’s expectation first: validate → explain → negotiate

🤝

Common expectation: “I want antibiotics” or “Does this mean I will need surgery?”

Validate — the antibiotic expectation is completely understandable

For decades, antibiotics were the standard treatment for diverticulitis, and most patients have either been given them before or expect them now. Acknowledging that this is a completely reasonable expectation — and that the guidance has changed relatively recently based on new evidence — is much more effective than simply refusing.

“I completely understand why you are expecting antibiotics — that was the standard treatment for many years. But I want to explain why the evidence has led us to change that approach for milder attacks like this one.”

Explain — the NICE NG147 watchful waiting evidence

Large randomised controlled trials have shown that for uncomplicated diverticulitis in systemically well patients, antibiotics do not shorten recovery time, reduce complication rates, or prevent recurrence. The side effects (C. difficile, antibiotic resistance, allergic reactions) outweigh the minimal benefit in this population.

“Several large studies comparing antibiotics to no antibiotics in mild diverticulitis have found no difference in how quickly people recover, how many people needed surgery, or how many had complications. So for an attack like yours, the evidence does not support antibiotics — and they carry their own risks.”

Negotiate — give a clear safety-net and plan

The watchful waiting approach only works clinically and relationally if the patient has clear, specific criteria for when to seek help and confidence that they will be reassessed promptly. The safety-net IS the treatment plan. A 48-hour review is essential for all patients managed at home.

“What I can promise you is this: if things do not improve within 48–72 hours, or if they get worse in any of the specific ways I am going to describe, we will re-assess immediately — and at that point, antibiotics or hospital admission may be exactly the right thing. This is not me leaving you without support.”

7B — Treatment goals

Goals for acute diverticulitis management

Symptom resolution within 7–10 days in uncomplicated disease Adequate analgesia — paracetamol; NSAIDs must be avoided Adequate hydration — clear fluids; escalate if not tolerated CRP normalisation by 2–4 weeks post-attack Post-recovery colonoscopy within 6–8 weeks to exclude CRC High-fibre diet 30g/day in remission; NSAID avoidance No further diverticulitis episodes (recurrence reduction with lifestyle) Return to normal diet and activities within 2–3 weeks

Motivational language for the reluctant patient

“Most people with an attack like yours feel significantly better within 3–5 days with adequate fluids, rest, and pain relief. You do not need to be in hospital, but you do need to take this seriously and come back or call if things change.”

“The single most effective thing you can do to prevent another attack is increasing the fibre in your diet. That has better evidence than any medication for reducing recurrence — and the target is 30 grams a day.”

7C — Non-medication management

🍽️

Dietary Advice — Acute Phase

Low-fibre soft diet for 3–7 days; then step-up

During the acute attack

A temporarily low-fibre, soft-food diet reduces stool bulk and colonic workload, making the acute episode more comfortable. Clear fluids initially; introduce soft low-fibre foods as pain improves. This is a temporary measure — typically 3–7 days. Adequate fluid intake (at least 1.5–2L/day) is essential.

Transition to remission diet

Gradually increase fibre over 2–3 weeks post-attack to reach 30g/day. Both soluble and insoluble fibre are beneficial. Ispaghula husk (Fybogel) can supplement dietary intake if 30g/day is difficult to achieve through food alone.

High-fibre diet (30g/day) significantly reduces recurrence risk; also reduces CRC risk

🚫

Correcting the Seeds & Nuts Myth

No evidence for restriction; harmful to advise

The old advice

For decades, patients with diverticulosis were advised to avoid seeds, nuts, corn, and popcorn, based on the theoretical concern that these particles could lodge in diverticula and trigger inflammation. This advice was never based on clinical evidence.

What the evidence shows

Prospective cohort studies have found no association between nut, seed, or popcorn consumption and diverticulitis. In fact, nuts are an excellent source of fibre and have been associated with reduced diverticulitis risk. Continuing to advise restriction deprives patients of a nutritionally valuable, high-fibre food source.

Correcting this myth allows patients to eat a nutritionally complete high-fibre diet without fear

🚫

NSAID Avoidance

3× increased risk of perforation; use paracetamol

Why NSAIDs are harmful

NSAIDs inhibit prostaglandin synthesis, reducing the mucosal protective mechanisms of the colonic wall. Regular NSAID use is associated with a 3-fold increase in the risk of diverticular perforation and haemorrhage. This applies to all NSAIDs, including low-dose aspirin in higher doses.

What to use instead

Paracetamol 1g QDS is the analgesic of choice in diverticular disease. Opiates cause constipation and worsen diverticular disease; use the lowest effective dose with stool softeners if unavoidable. Document NSAID avoidance advice at every consultation.

NSAID avoidance is one of the most evidence-based interventions in reducing diverticular complications

🏋

Exercise

Regular exercise reduces diverticulitis risk and recurrence

Evidence

Physical inactivity is an independent risk factor for diverticular disease. Prospective studies show that men with the highest physical activity levels have 37% lower risk of diverticulitis compared with the least active. Exercise improves colonic motility and reduces constipation, both of which reduce diverticular disease risk.

Practical advice

150 minutes/week moderate aerobic activity in remission. Rest during the acute attack. Walking is an excellent and accessible activity. Even modest increases in activity from a sedentary baseline significantly reduce risk.

Regular exercise reduces diverticulitis risk by up to 37% and reduces constipation

💧

Hydration

1.5–2L water/day; essential for fibre to work

Why hydration matters

Dietary fibre absorbs water and requires adequate hydration to soften stool and maintain colonic transit. Increasing fibre without adequate hydration causes constipation and worsens diverticular disease. The two must be increased together.

Practical advice

Aim for 1.5–2L of water per day (including other drinks). During the acute attack, clear fluids are the priority. Avoid excessive caffeine and alcohol, both of which cause dehydration and worsen colonic function.

Adequate hydration is essential for dietary fibre to work; reduces constipation and diverticular disease

🨯

Weight Management

Obesity is a risk factor for diverticulitis and complications

Evidence

Obesity (BMI >30) is an independent risk factor for diverticular disease and for more severe complications. Abdominal adiposity impairs colonic motility and increases intra-abdominal pressure, predisposing to diverticular formation.

Practical advice

Weight management counselling; referral to Tier 3 weight management services if BMI >35; high-fibre diet for diverticular disease also supports weight management. Exercise has dual benefit.

Weight management reduces diverticulitis risk, severity, and surgical complication rate

7D — Prescribing guide: acute diverticulitis management

NICE NG147 (2019) recommends watchful waiting without routine antibiotics for uncomplicated acute diverticulitis in systemically well patients. Antibiotics are reserved for: complicated diverticulitis (Hinchey I–II), immunocompromised patients, patients who fail to improve within 72 hours of watchful waiting, or patients who are systemically unwell at presentation.

First-line: analgesia & watchful waiting

Paracetamol 1g QDS: First-line analgesia; safe and effective; does not worsen diverticular disease
Adequate hydration: At least 1.5–2L/day; clear fluids initially if pain is severe; avoid dehydration which worsens the acute attack
Low-fibre diet: Soft foods during acute attack for 3–7 days; then gradually increase to high-fibre 30g/day in remission
Rest: Avoid strenuous activity during the acute attack; resume gradually as pain resolves
🔴 NSAIDs are contraindicated (3× perforation risk); opiates worsen constipation and diverticular disease

NICE NG147: no routine antibiotics for uncomplicated disease in systemically well patients

Antibiotics: when to use (complicated disease)

Co-amoxiclav 625mg TDS × 5–7 days (oral): If antibiotics are indicated and patient can tolerate oral intake; covers Gram-negative and anaerobic organisms; penicillin allergy alternative: metronidazole 400mg TDS + ciprofloxacin 500mg BD
Metronidazole 400mg TDS + ciprofloxacin 500mg BD: For penicillin allergy or per local formulary; cover for anaerobes (metronidazole) + Gram-negatives (ciprofloxacin)
Hospital IV antibiotics (co-amoxiclav 1.2g TDS IV or piperacillin-tazobactam): For complicated diverticulitis (Hinchey I–II); hospital-initiated
🔴 Indications for antibiotics: CRP >150; immunocompromised; fever >38.5°C; failure to improve at 72 hours; Hinchey classification I–II

Do NOT routinely prescribe for uncomplicated disease; explain NICE NG147 evidence to patient

Long-term management: prevention of recurrence

High-fibre diet 30g/day: The most effective intervention for preventing recurrence; both soluble and insoluble fibre; increase gradually to avoid bloating
Ispaghula husk (Fybogel) 1 sachet BD: Soluble fibre supplement if dietary 30g/day is difficult to achieve; dissolve in water; adequate fluid essential
Mesalazine (5-ASA): Weak and inconsistent evidence for preventing recurrence after acute diverticulitis; not currently recommended routinely by NICE; may be considered under specialist guidance after multiple episodes
Probiotics: Insufficient evidence to recommend routinely; some studies suggest benefit in diverticular disease maintenance; individual patient discussion

High fibre 30g/day is the strongest evidence-based long-term intervention; NSAID avoidance essential

7E — Drug reference cards: diverticulosis pharmacotherapy

Paracetamol

Paracetamol 500mg · Paracetamol 1g (prescription) · Solpadol (paracetamol + codeine — use with caution)

✓ First-line analgesia

First-line1g QDS (max 4g/day)

✓ Use when

All acute diverticulitis episodes requiring analgesia — paracetamol is the only recommended simple analgesic

Regular dosing (1g QDS) is more effective than PRN dosing for maintaining analgesia during acute attack

Safe in renal impairment (unlike NSAIDs); safe in the elderly; no GI side effects

✗ Avoid

NSAIDs (ibuprofen, naproxen, diclofenac, aspirin analgesic doses): 3× increased risk of diverticular perforation and haemorrhage — absolutely contraindicated in diverticular disease

Opiates (codeine, tramadol, morphine): cause constipation and worsen diverticular disease; use with great caution and only if paracetamol is inadequate; always with stool softeners

🔬 Notes

If paracetamol is inadequate alone: consider short-course paracetamol + low-dose weak opiate with stool softener; NOT NSAIDs

Paracetamol 1g (prescription strength) is more effective than OTC 500mg doses for severe diverticulitis pain

💬 Counselling

“Paracetamol is the best painkiller for this condition — take it regularly every 4–6 hours, up to 4 doses a day, rather than waiting until the pain is severe. Avoid any anti-inflammatories like ibuprofen — they can make diverticular disease significantly worse and increase the risk of a serious complication.”

SCA pearl: The most commonly scored prescribing error in diverticulitis is either prescribing NSAIDs for pain (dangerous — 3× perforation risk) or failing to advise on NSAID avoidance. Stating explicitly that paracetamol is preferred AND that NSAIDs must be avoided is a key Tasks domain scoring item. Opiates causing constipation and worsening diverticular disease is a secondary but important point.

Co-amoxiclav

Augmentin 625mg · Co-amoxiclav 625mg · 250/125mg formulation

✓ If antibiotics indicated (NICE criteria)

Conditional — complicated or failing625mg TDS × 5–7 days

✓ Use when

CRP >150 mg/L and patient is managing at home (complicated but not requiring admission)

Immunocompromised patient with any diverticulitis episode

Failure to improve after 72 hours of watchful waiting

Per local formulary guidelines; check NICE NG147 criteria are met before prescribing

✗ Avoid / caution

Penicillin allergy: use metronidazole 400mg TDS + ciprofloxacin 500mg BD instead

C. difficile risk: document, warn patient; diarrhoea on antibiotics → stop and test for C. difficile

Not for uncomplicated diverticulitis in well patients — NICE NG147 does not support routine use; explain this to patient if antibiotic expectation is present

🔬 Notes

Check local antimicrobial guidelines — formulary may differ; ciprofloxacin + metronidazole is an equally acceptable alternative per local guidelines

If prescribed: 5–7 day course; review at 72 hours; if not improving, hospital admission

💬 Counselling

“I am prescribing antibiotics because your blood results and your symptoms suggest this is a more severe episode. Take them regularly with food. If you develop diarrhoea, particularly after finishing the course, come back — antibiotics can occasionally cause their own gut infection that needs treatment.”

SCA pearl: The key scoring point is that NICE NG147 does NOT recommend routine antibiotics for uncomplicated diverticulitis — stating this clearly and explaining the rationale to the patient scores in both Tasks (correct clinical decision) and Relating to Others (antibiotic expectation managed). Prescribing co-amoxiclav for an uncomplicated episode in a well patient without explaining this contradiction is a partial deduction. Always link prescribing to specific NICE criteria.

Ispaghula Husk (Fybogel)

Fybogel sachets · Regulan · Metamucil · Isogel

✓ Long-term remission

Maintenance1 sachet BD in water

✓ Use when

Patient is in remission and unable to achieve 30g/day dietary fibre through food alone

Soluble fibre supplement that softens stool and improves colonic transit

Also useful for chronic diverticular symptoms (bloating, intermittent pain) in remission

✗ Caution

Do NOT use during an acute attack of diverticulitis — bulk-forming laxatives worsen acute pain; switch to low-fibre diet acutely

Adequate fluid intake is essential — without sufficient water, ispaghula can cause constipation or bowel obstruction

🔬 Notes

Increase fibre gradually (over 2–4 weeks) to minimise initial bloating and flatulence

Dietary fibre is preferable to supplements where achievable; Fybogel is a supplement, not a replacement for high-fibre diet

💬 Counselling

“This is a fibre supplement to help you reach the recommended 30g of fibre a day. Dissolve it fully in a full glass of water — not a small amount. Take it after meals. It may cause some bloating initially as your bowel gets used to the extra fibre; this usually settles within 2–3 weeks. Stop it during any acute attack.”

SCA pearl: Ispaghula husk scores in Tasks domain if mentioned in the context of long-term fibre supplementation and recurrence prevention. The key distinction is that it is for remission, not for acute attacks. Knowing the 30g/day target and that dietary fibre is preferable to supplements demonstrates clinical depth.

7F — Psychosocial impact

🤝

Living with recurrent diverticular disease — chronic impact

📈

Cancer Vigilance Without Catastrophising

Diverticulosis is common and real, but it cannot be used to explain away symptoms that require cancer exclusion. The GP must maintain active cancer surveillance without causing unnecessary anxiety. The two-step approach — manage the acute episode AND arrange post-recovery colonoscopy — addresses both clinical and psychological needs.

“We are treating the current attack and we will also arrange a camera test once you are better — this is to make absolutely sure we have the full picture and are not missing anything. This is standard care, not because I am worried.”

🍽️

Food Anxiety and Dietary Myths

Many patients with diverticular disease have significant anxiety about food, restricting their diet unnecessarily based on outdated advice. Correcting the seeds and nuts myth and providing evidence-based dietary guidance significantly reduces food anxiety and improves nutrition and quality of life.

“I want to liberate you from the worry about seeds and nuts — the research is clear that they do not cause attacks. A varied, high-fibre diet including all these foods is what helps most.”

🚪

Surgery Fear and Recurrence Anxiety

Fear of needing a stoma or emergency surgery is a dominant concern. Most patients with even recurrent diverticulitis do not require emergency surgery. Elective sigmoid colectomy, when indicated, is usually laparoscopic and avoids stoma. Accurate information significantly reduces surgery-related anxiety.

“I want to reassure you that the vast majority of people with diverticulitis — even those with repeated attacks — do not end up needing emergency surgery. If we ever get to the point of discussing planned surgery, that would be a carefully considered decision made together.”

🏢

Practical Daily Life

Recurrent diverticulitis episodes cause missed work and social disruption. NSAID use (common for musculoskeletal pain in this age group) must be addressed. Exercise and weight management improve diverticular disease outcomes and overall wellbeing.

“Is there anything in your regular medications or your lifestyle that we should look at together? I am particularly thinking about any anti-inflammatories you might be taking for joint pain or other conditions.”

7G — Follow-up schedule

48–72 hours — Mandatory review for all home-managed patients

Clinical assessment: pain improving? Tolerating fluids and light diet? Any new symptoms (fever, vomiting, bleeding)? Repeat CRP if initial CRP was borderline (50–150). If deteriorating or CRP not falling: hospital admission. This review is not optional — it is the safety mechanism that makes community management safe.

Mandatory — all home-managed cases

7–10 days — Recovery confirmation

Confirm resolution of acute episode; repeat CRP to confirm falling; dietary advice reinforced (begin transitioning to high-fibre diet); NSAID avoidance counselling; plan post-recovery colonoscopy referral; seeds/nuts myth corrected if not already done.

Recovery check

6–8 weeks — Post-recovery colonoscopy

Arrange colonoscopy (either via GP referral or gastroenterology) to exclude CRC after first episode. Confirm CRP normalised. Ensure high-fibre diet is established. Annual review appointment booked.

Colonoscopy (CRC exclusion)

Annual review — diverticular disease monitoring

Episode frequency and severity; medication review (NSAID avoidance); dietary fibre adherence; exercise; weight management; mental health (anxiety about recurrence); colonoscopy / CRC surveillance up to date; elective surgery discussion if ≥2 episodes; FBC if PR bleeding has been an issue.

AnnualColonoscopy surveillance

Open access — urgent triggers for A&E

A&E if: peritonism (guarding/rebound/rigidity); fever >38.5°C with severe pain; large PR bleeding with haemodynamic symptoms (dizziness, pallor); vomiting and unable to maintain fluids; severe pain not controlled with paracetamol; any significant deterioration in the first 72 hours of community management.

A&E triggers — communicated clearly

7H — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

Watchful waiting without clear A&E criteria and a 48–72 hour review is clinically insufficient — document both at every home-management consultation

Post-recovery colonoscopy not arranged after first diverticulitis episode is a documented quality gap; document referral discussion and timing at every opportunity

Attributing persistent symptoms to diverticulosis without CRC exclusion is a documented cause of delayed CRC diagnosis; 2WW if symptoms >6 weeks

NSAID prescribing in diverticular disease (associated with 3× perforation risk) must be documented as avoided; document NSAID avoidance advice at every consultation

Failing to recognise colovesical fistula in a patient with recurrent UTIs and known diverticular disease — polymicrobial UTI and pneumaturia are diagnostic; document assessment

Palpable abdominal mass in diverticular disease attributed to diverticulosis without CT imaging — carcinoma must be excluded; document imaging decision at every mass assessment

48–72 hoursMandatory review for all home-managed acute episodes

7–10 daysRecovery confirmation; CRP check; dietary transition

6–8 weeksPost-recovery colonoscopy (CRC exclusion)

AnnualMedication review; NSAID avoidance; fibre; elective surgery if ≥2 episodes

Urgent/anytimePeritonism; fever >38.5°C; PR haemorrhage; unable to maintain fluids → A&E

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

“Is there anything else worrying you — anything I have said today that you want me to go through again?”

“To summarise: paracetamol regularly for pain, clear fluids, no ibuprofen at all. I will see you or speak to you in 48–72 hours. If your temperature goes above 38 degrees or the pain becomes severe — A&E, not this surgery.”

“Once this settles, I am going to arrange a colonoscopy — standard practice to check everything looks right. And the most important thing for preventing another attack is building up your fibre intake gradually to 30g a day.”

“Antibiotics have not been given because the current guidance shows they do not help in a mild episode like yours. But if things do not improve in 48–72 hours, we will reconsider.”

Deductions — closing

Not arranging a 48–72 hour review for all home-managed patients
Not mentioning post-recovery colonoscopy
Prescribing NSAIDs or not advising avoidance
Not giving specific A&E criteria (fever threshold, peritonism, haemorrhage)
No closing question for remaining concerns

Tasks domain — full criteria

CRP threshold communicated (CRP >150 = hospital)
NICE NG147 watchful waiting explained; antibiotic expectation negotiated
Paracetamol prescribed; NSAIDs explicitly contraindicated
48–72 hour mandatory review arranged
Post-recovery colonoscopy (6–8 weeks) planned

Relating to Others — full criteria

Antibiotic expectation validated before explaining NICE evidence
Surgery/cancer fear acknowledged and addressed with specific information
Seeds and nuts myth corrected without being patronising
Plan negotiated; patient’s concerns addressed throughout
Specific A&E criteria communicated clearly, not vaguely
Closing question asked

🔴 Red — failing

NSAIDs prescribed · Complicated diverticulitis managed at home · No 48–72 hour review · Colonoscopy not planned · Antibiotic expectation not explored · CRC not considered

🟠 Amber — borderline

NICE NG147 mentioned but not explained to patient · Review arranged but timing vague · Colonoscopy mentioned but not explained why · Dietary advice incomplete

🟢 Green — passing

NICE NG147 evidence explained · Antibiotic expectation negotiated · Paracetamol + NSAIDs avoided · 48–72 hour review confirmed · Post-recovery colonoscopy planned · A&E criteria specific · 30g/day fibre goal · Closing question

“I have had this terrible pain in my left side for three days now and I am running a bit of a temperature. I had something like this two years ago and they gave me antibiotics and it settled. I am expecting the same today — I just need a course of antibiotics and I will be fine.”

Who you are

Patricia, 58 years old, retired school administrator. Known diverticulosis diagnosed on colonoscopy 3 years ago. Has had one previous episode of diverticulitis 2 years ago, managed with a 5-day course of co-amoxiclav by her previous GP. Current episode: 3-day history of left iliac fossa pain (constant, 6/10 severity), low-grade temperature of 37.5°C at home, nausea but managing to sip fluids. No vomiting. No significant PR bleeding (a small amount of mucus on one occasion). No peritonism — tender but not rigid. Is able to mobilise. CRP 78 mg/L (blood result available). Has been taking ibuprofen for the pain “because that is what I always use for pain.”

Hidden agenda and ICE

Frightened this is something worse this time — specifically worried it could be bowel cancer because her mother had it. Embarrassed to mention the cancer fear without being directly asked. Firmly expects antibiotics because “that is what I got before and it worked.” Worried about surgery — a friend had an emergency colostomy for diverticulitis. Taking ibuprofen at home which is worsening the diverticular disease (must be asked about specifically). Has not been told about the seeds and nuts restriction being outdated and still avoids them.

Symptoms if asked directly

LIF pain: constant, 6/10, worse on movement; started 3 days ago
Temperature: 37.5°C at home; no rigors
Nausea: present; managing small sips of fluid; no vomiting
Bowel habit: slightly loose; small amount of mucus once; no significant bleeding
Urinary symptoms: none
Weight loss: none; appetite reduced for 3 days due to nausea
Ibuprofen use: 400mg TDS for the past 3 days for the pain
Duration of current episode: 3 days; similar to 2 years ago
Last colonoscopy: 3 years ago (the diagnostic one); no follow-up scope arranged

Bonus details and resolution

Ibuprofen use: only discloses if specifically asked about pain relief; may say “just ibuprofen, which is what I normally take” — this is a scored finding; must be stopped immediately
Cancer fear: will not volunteer it; discloses if asked “is there anything specific you are worried this might be?” — “yes, my mother had bowel cancer and I keep thinking...”
Seeds/nuts: volunteers “I still avoid seeds and nuts, is that right?” if dietary advice is discussed
Challenge phrase: “But antibiotics worked last time — why can I not just have them again? I do not understand why you are doing things differently now.”
Resolution: accepts watchful waiting if the clinician explains NICE NG147 evidence clearly AND provides specific A&E criteria AND confirms a 48–72 hour review. Remains resistant if only told “antibiotics are not needed” without evidence or review plan. Cancer fear must be specifically acknowledged and addressed — she will remain anxious if it is not named. Ibuprofen must be stopped and paracetamol prescribed instead.

“I really think I need antibiotics — they worked perfectly last time and I do not understand why you are not giving them to me. I am in pain and I am worried. Can you not just give me the same ones as before?”

Resolution: Accept watchful waiting if the clinician: (1) explains NICE NG147 clearly — “the evidence from large studies shows antibiotics do not help in mild cases like yours”; (2) arranges a specific 48–72 hour review; (3) gives specific A&E criteria (fever >38°C, severe pain, vomiting, unable to keep fluids down); (4) specifically stops the ibuprofen and prescribes paracetamol; (5) addresses the cancer fear directly. Award bonus marks if the seeds/nuts myth is corrected without being patronising and if post-recovery colonoscopy is planned and the reason explained as cancer exclusion (not as routine).

🏥

Clinic Quick Reference

Diverticulosis & Diverticulitis — Clinical Decision Framework

NICE NG147 (2019) · CKS 2023 · Acute Management and Surveillance

▼expand

🚨 1 — Triage by Severity

Suspected acute diverticulitis — assess severity using CRP, fever, peritonism, and oral tolerance

↓

🔴 Emergency / Hospital Admission

Peritonism (guarding / rebound / rigidity) → 999
CRP >150 mg/L → hospital admission
Fever >38.5°C + severe pain → hospital
Large PR bleeding + haemodynamic compromise → 999
Unable to maintain oral fluids → hospital (IV fluids needed)

Same-day admission; CT abdomen; IV antibiotics (hospital)

🟠 Monitor Closely

CRP 50–150 → close GP review at 24–48 hours
Mild fever 37.5–38.4°C + well patient
Symptoms >6 weeks or new change in bowel habit → 2WW CRC
Palpable abdominal mass → urgent CT + 2WW CRC
Recurrent episodes (≥2) → colorectal surgery referral

Review at 24–48 hours; repeat CRP; 2WW if red flags

🟢 Community Management (NICE NG147)

CRP <150 + systemically well
No peritonism; tolerating oral fluids
Temp <38°C or mild fever only
No significant PR bleeding

Watchful waiting; paracetamol; low-fibre diet; 48–72 hr review

📊 2 — Key Numbers

CRP >150

Threshold for hospital admission — complicated diverticulitis

48–72 hrs

Mandatory review for all home-managed patients

6–8 weeks

Post-recovery colonoscopy (CRC exclusion after 1st episode)

30g/day

Target dietary fibre in remission (prevention of recurrence)

50% at 50

Diverticulosis prevalence by age 50; 70% by age 70

Only 5%

Of diverticulosis patients develop diverticulitis

3× risk

NSAID use increases perforation risk — switch to paracetamol

No routine antibiotics

NICE NG147: watchful waiting for uncomplicated diverticulitis

Hinchey I–II

Abscess → CT-guided drainage + IV antibiotics (hospital)

Hinchey III–IV

Perforation / peritonitis → 999; emergency laparotomy

≥2 episodes

Recurrence threshold for elective sigmoid colectomy discussion

No seed restriction

Seeds/nuts do NOT cause diverticulitis — outdated advice; correct this myth

💊 3 — Management Decision Summary

Acute diverticulitis management at a glance

Step 1 — Assess severity: CRP + fever + peritonism + oral tolerance
Step 2 — Triage: CRP >150 / peritonism / unable to take fluids → hospital
Step 3 — Community (if eligible): Watchful waiting per NICE NG147
  • Paracetamol 1g QDS (NOT NSAIDs — 3× perforation risk)
  • Low-fibre diet acutely; clear fluids; adequate hydration
  • Review at 48–72 hours; specific A&E criteria communicated
Step 4 — Antibiotics (if indicated): CRP >150 / immunocompromised / not improving at 72 hours
  • Co-amoxiclav 625mg TDS ×5–7 days (penicillin allergy: ciprofloxacin + metronidazole)
Step 5 — Post-recovery: Colonoscopy 6–8 weeks; high-fibre diet 30g/day

Critical rules

🔴 NSAIDs contraindicated in diverticular disease (3× perforation risk)
🔴 Opiates cause constipation — worsen diverticular disease
🔴 No routine antibiotics for uncomplicated diverticulitis (NICE NG147)
🔴 Colonoscopy contraindicated during acute attack (perforation risk)
🔴 Post-recovery colonoscopy mandatory after first episode
🔴 Do NOT attribute persistent symptoms to diverticulosis — exclude CRC
🔴 Palpable mass → CT urgently; 2WW CRC
✅ Seeds and nuts restriction is outdated — correct this myth
✅ 30g/day fibre in remission — strongest evidence for recurrence prevention
✅ CRP is the most important primary care investigation in diverticulitis

⚠ 4 — Safety Netting & Follow-Up

Follow-up timeline

48–72 hours: Mandatory review; pain improving? Tolerating fluids? Repeat CRP if needed

7–10 days: Recovery confirmed; dietary transition to high-fibre; NSAID avoidance

6–8 weeks: Post-recovery colonoscopy (CRC exclusion); confirm CRP normalised

Annual: Episode frequency; medications; diet; elective surgery if ≥2 episodes

Urgent anytime: Peritonism; fever >38.5°C; PR haemorrhage; unable to take fluids → A&E

🔴 48–72 hour review is mandatory for ALL home-managed cases

🔬 5 — Hinchey Classification Quick Reference

Hinchey Grade	Finding	Management
I — Pericolic abscess	Small abscess in mesentery; confined to colon	Hospital; IV antibiotics; CT; drainage if >3cm
II — Pelvic/distant abscess	Larger abscess away from perforation site	Hospital; CT-guided percutaneous drainage; IV antibiotics; surgery if drainage fails
III — Purulent peritonitis	Free purulent pus in peritoneal cavity	999; emergency Hartmann’s procedure; sigmoid resection + end colostomy; HDU/ICU
IV — Faecal peritonitis	Free faecal contamination of peritoneal cavity	999; emergency laparotomy; Hartmann’s; aggressive resuscitation; mortality 30–50%
Uncomplicated (pre-Hinchey)	LIF pain + raised CRP; no abscess, no perforation	NICE NG147 watchful waiting; no routine antibiotics; paracetamol; 48–72 hour review

🔴 Red flags → A&E / 999: Peritonism (guarding/rebound) · CRP >150 mg/L · Fever >38.5°C + severe pain · Haemodynamic compromise (PR bleeding) · Unable to maintain oral fluids · Palpable abdominal mass · Immunocompromised patient with any diverticulitis

🟠 Must NOT do: NSAIDs (3× perforation risk) · Colonoscopy during acute attack · Attribute all symptoms to diverticulosis without CRC consideration · Omit post-recovery colonoscopy · Miss 2WW criteria (symptoms >6 weeks / weight loss / change in bowel habit) · Seeds/nuts restriction (outdated advice)

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Consultation Flow

0–2 min

Open + Severity Screen

“Tell me about the pain — where exactly, how long, and how have you been managing with food and drink?”

Open question then immediately assess severity: fever, vomiting, peritonism, CRP. These determine whether this is a community or hospital management situation within the first 2 minutes.

Relating to OthersTasks

✗ No severity assessment · Not asking about tolerance of oral fluids · Not checking for PR bleeding

2–5 min

Targeted History — Red Flags & CRC Screen

“Have you noticed any blood in the stools? Any change in your bowel habit over the last few weeks? Any weight loss? Any problem passing urine or any unusual symptoms with urination?”

PR bleeding (haemorrhage risk), change in bowel habit >6 weeks (2WW CRC), weight loss (CRC red flag), urinary symptoms (colovesical fistula). Ask about current medications — specifically NSAIDs.

Tasks

✗ Not asking about PR bleeding · Not screening for CRC red flags · Not asking about NSAIDs or current analgesia

5–7 min

ICE + Examination

“I can tell you were expecting antibiotics — and I want to address that directly. But first, are you worried about something more serious, like cancer? I ask because your mother had bowel cancer and I want to be thorough.”

Examine: vital signs (peritonism assessment is essential), abdominal palpation for tenderness and mass, urine dipstick if urinary symptoms. Explore antibiotic expectation and cancer/surgery fears during or after examination.

Relating to OthersTasks

✗ No peritonism assessment · Cancer fear not raised · Antibiotic expectation not acknowledged

7–10 min

Diagnosis + NICE NG147 + NSAID Stop

“Based on the examination and your CRP result, this is consistent with diverticulitis. The ibuprofen you have been taking actually makes diverticular disease more dangerous — please stop it now and switch to paracetamol. And regarding antibiotics — the evidence has changed.”

Stop NSAIDs immediately. Explain NICE NG147 watchful waiting with evidence. Arrange 48–72 hour review. Plan post-recovery colonoscopy. Seeds/nuts myth corrected. 30g/day fibre target.

TasksRelating to Others

✗ NSAIDs not stopped · NICE NG147 not explained · Antibiotics prescribed without context · No post-recovery colonoscopy mentioned

10–12 min

Safety-Net + Follow-Up + Close

“I will see you or phone you in 48–72 hours — that review is essential. Go straight to A&E if: fever above 38, tummy goes rigid, severe vomiting, or you cannot keep fluids down. Once you recover, I am arranging a colonoscopy to check everything looks right. Is there anything else worrying you?”

Specific A&E criteria. 48–72 hour review confirmed. Post-recovery colonoscopy reason explained. Seeds/nuts myth corrected. Closing question.

TasksRelating to OthersGlobal Skills

✗ No closing question · A&E criteria vague · 48–72 hour review not confirmed · Colonoscopy not mentioned

🔴🟠🟢 RAG Scoring

Tasks Domain

🟢

CRP threshold applied · Peritonism assessed · NICE NG147 explained · NSAIDs stopped · Paracetamol prescribed · 48–72 hr review · Post-recovery colonoscopy · CRC differential raised · 30g/day fibre

🟠

Severity assessed but CRP threshold not linked · NICE NG147 mentioned but not explained · Colonoscopy not planned · NSAIDs not specifically stopped

🔴

NSAIDs prescribed or not stopped · Complicated diverticulitis managed at home · No 48–72 hour review · CRC not considered · Post-recovery colonoscopy omitted

Relating to Others

🟢

Antibiotic expectation validated + negotiated · Cancer fear named · Surgery fear addressed · Seeds/nuts corrected · Plan negotiated · Closing question

🟠

Antibiotics refused without negotiation · Cancer fear not raised · Seeds/nuts not addressed · No closing question

🔴

Antibiotic expectation not explored · Plan imposed without negotiation · Cancer fear dismissed · A&E criteria not given

Global Skills

🟢

Systematic · Severity early · Plain language · NICE evidence explained · Clear summary with specific A&E criteria and review date

🟠

Structure but severity assessment late · Medical jargon (Hinchey) unexplained · Summary vague · Review not confirmed

🔴

No structure · No severity assessment · NSAIDs not addressed · No follow-up plan · Patient left without A&E criteria

💬 Key Phrases

Severity assessment — the pivotal question

“The most important thing I want to check first is whether this needs hospital treatment today or whether it is safe to manage at home — and the key questions are your temperature, whether you can keep fluids down, and an examination of your tummy.”

Cancer fear — name it directly

“Are you worried this might be something more serious — like cancer? I want to address that specifically. The symptoms fit diverticulitis, but I am also arranging a camera test once you recover to make absolutely sure.”

Antibiotic expectation — validate then negotiate

“I completely understand why you are expecting antibiotics — they were the standard treatment for years. Large studies now show they do not actually help in mild cases like yours and come with their own risks. What they gave you before may have settled on its own too.”

NSAIDs — stop immediately

“The ibuprofen is something I need to ask you to stop right away. Anti-inflammatories are actually one of the main things that increase the risk of a serious complication with diverticulitis — they make the bowel wall more vulnerable. Use paracetamol instead.”

Seeds and nuts — correct the myth

“The advice about avoiding seeds and nuts has been around for a long time, but it is not supported by the evidence. The opposite is actually true — a high-fibre diet including seeds and nuts is what we recommend when you are well.”

Close — safety-net and review

“I will review you in 48–72 hours — that is essential. Go straight to A&E if: temperature above 38 degrees, tummy goes very rigid, severe vomiting, or you cannot keep any fluids down. I am arranging a colonoscopy 6–8 weeks after you recover.”

🚫 9 Danger Zones — Instant Deductions

✗

Prescribing NSAIDs for diverticulitis pain→ NSAIDs increase perforation risk 3-fold; paracetamol is the only safe analgesic; stop any NSAIDs the patient is already taking

✗

Managing CRP >150 or peritonism at home→ CRP >150 or peritonism = hospital admission; complicated diverticulitis cannot be managed in primary care

✗

Prescribing antibiotics without NICE NG147 context→ No routine antibiotics for uncomplicated disease; if prescribed, must explain the specific indication and that NICE guidance does not support routine use

✗

Arranging colonoscopy during acute attack→ Perforation risk; colonoscopy only after recovery at 6–8 weeks; CT is the acute imaging investigation

✗

Attributing all symptoms to diverticulosis without CRC consideration→ Symptoms >6 weeks / weight loss / change in bowel habit / mass = 2WW CRC referral regardless of known diverticulosis

✗

No 48–72 hour review for home-managed patients→ Review is the safety mechanism; watchful waiting without a review appointment is clinically inadequate and medico-legally unsafe

✗

Not arranging post-recovery colonoscopy→ Mandatory after first episode of diverticulitis to exclude CRC; document this referral before the patient leaves

✗

Reinforcing the seeds and nuts restriction→ No evidence for this restriction; the opposite is true — high-fibre diet including seeds and nuts is recommended in remission

✗

Missing colovesical fistula (recurrent UTIs + known diverticular disease)→ Polymicrobial UTI / pneumaturia / faecaluria = fistula until excluded; urgent urology + colorectal surgery + CT fistulogram

💊 Management Quick Reference

Uncomplicated (NICE NG147)

→

Watchful waiting (no antibiotics)

48–72 hr review

Analgesia — first-line

→

Paracetamol 1g QDS

NOT NSAIDs; NOT opiates

Antibiotics (if indicated)

→

Co-amoxiclav 625mg TDS

5–7 days; NICE criteria only

Penicillin allergy

→

Ciprofloxacin + metronidazole

Per local formulary

Long-term remission

→

High fibre 30g/day + Fybogel

NSAID avoidance lifelong

Post-recovery (first episode)

→

Colonoscopy at 6–8 weeks

CRC exclusion — mandatory

🔴 CRP >150 = hospital · Peritonism = 999 · NSAIDs = contraindicated · No acute colonoscopy · 48–72 hr review non-negotiable · Post-recovery colonoscopy mandatory

Diverticulosis & Diverticulitis · GP Clinical Reasoning Framework v2 · NICE NG147 (2019) · NICE CKS Diverticular Disease (2023) · BSG Diverticular Disease Guidelines · Hinchey Classification (1978, modified 2006)

v2: NICE NG147 watchful waiting without routine antibiotics as core management framework · CRP >150 as hospital admission threshold · Hinchey classification for surgical severity · Post-recovery colonoscopy mandatory after first episode · Seeds and nuts restriction myth corrected · 30g/day fibre target · NSAIDs 3× perforation risk · 48–72 hour review mandatory · Colovesical fistula pathway · CRC differential at every consultation · SCA RAG checkpoints · Scorecard · Dual summaries

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/SPC and local antimicrobial guidelines · NICE NG147 represents a significant change from previous practice; explain the evidence to patients · Clinical judgement takes precedence over any framework

Diverticulosis & Diverticulitis

Red Flags — act before continuing history

Safeguarding Considerations

👴 Frail Older Adults

💊 NSAIDs and Polypharmacy

🏠 Social Isolation and Self-Neglect

💐 Cancer Fear and Diagnostic Certainty

🍽️ Diet and Lifestyle Anxiety

🧠 Surgery Fear and Recurrence Anxiety

📈 Cancer Fear

🏢 Work, Activities, and Quality of Life

999 / Same-Day Hospital

Urgent Assessment

Primary Care Management

Asymptomatic Diverticulosis

Uncomplicated Acute Diverticulitis

Complicated Acute Diverticulitis (Hinchey I–IV)

Diverticular Haemorrhage

Colorectal Cancer (CRC)

Urinary Tract Infection (UTI)

Ovarian Pathology (women)

Irritable Bowel Syndrome

Hinchey I — Pericolic Abscess

Hinchey II — Pelvic or Distant Abscess

Hinchey III — Purulent Peritonitis

Hinchey IV — Faecal Peritonitis

Validate — the antibiotic expectation is completely understandable

Explain — the NICE NG147 watchful waiting evidence

Negotiate — give a clear safety-net and plan

Cancer Vigilance Without Catastrophising

Food Anxiety and Dietary Myths

Surgery Fear and Recurrence Anxiety

Practical Daily Life

48–72 hours — Mandatory review for all home-managed patients

7–10 days — Recovery confirmation

6–8 weeks — Post-recovery colonoscopy

Annual review — diverticular disease monitoring

Open access — urgent triggers for A&E

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda and ICE

Symptoms if asked directly

Bonus details and resolution