Management of Acute Diverticulitis in the East Anglian Region: Results of a United Kingdom Regional Survey

Purpose

Acute diverticulitis is the most common presentation of diverticular disease; however, no published guidelines for management are available in the United Kingdom. This survey was designed to assess the current United Kingdom regional practice compared with the guidelines published by The American Society of Colon and Rectal Surgeons.

Methods

A questionnaire survey focused on the management of acute diverticulitis was sent to all consultants, specialist registrars, and staff-grade surgeons in general surgery in one United Kingdom region.

Results

Eighty-two questionnaires were returned (80 percent). A majority (80 percent) would request routine blood tests, abdominal, and erect chest x-rays on arrival. Pethidine (56 percent) was the preferred analgesic, followed by morphine (40 percent). Ninety-four percent used an antibiotic combination of second/third-generation cephalosporin and metronidazole. Computerized tomography was the most commonly used initial investigation (42 percent). Forty percent use barium enema and 31 percent use a combination of barium enema and sigmoidoscopy as follow-up investigations. In patients older than aged 50 years, elective resection would be considered by a majority (51 percent) only when complications arose. In those aged 50 years or younger, 35 percent would resect only if complications arose with only 6 percent after a single episode of acute diverticulitis.

Conclusions

There are major differences in the management of patients with acute diverticulitis in our current practice in one United Kingdom region compared with the guidelines published by The American Society of Colon and Rectal Surgeons, which are based on published literature. There is an urgent need to establish similar guidelines in the United Kingdom to improve the clinical outcome of patients with such a common condition.

Appendix 1: Management of Acute Diverticulitis In The East Anglian Region

Grade of surgeon:

 □Consultant

 □Specialist Registrar

 □Staff Grade

 □Other: Please specify

Specialty:

 □General

 □Specialist Unit: Please specify

A patient presents to your firm as an emergency with a working diagnosis of acute diverticulitis. Please choose your options on the management of this patient. Please note that you can choose more than one option.

• 1. What initial investigations will you request for this patient?

  • □ Full blood counts □ Urea and electrolytes

  • □ Supine abdominal x-ray □ Erect chest x-ray

  • □ Urine analysis □ Other: Please specify

• 2. What would be your initial management?

  • □ Nil by mouth □ IV fluids

  • □ Normal diet □ Oral fluids

  • □ Analgesia □ Antibiotics

  • □ Other: Please specify

• 3. Which analgesic(s) would you normally prescribe and in what preference?

  • □ Pethidine □ Diclofenac

  • □ Morphine □ Codeine phosphate

  • □ Paracetamol □ Other: Please specify

• 4. What is your antibiotic(s) of choice for this patient? If you use a combination please indicate.

  • □ Cephalosporins □ Metronidazole □ Ciprofloxacin

  • □ Augmentin □ Gentamicin □ Imipenem

  • □ Other: Please specify

• 5. What further investigations do you request to confirm the diagnosis during the acute episode?

  • □ Ultrasound □ Gastrografin enema □ Barium enema

  • □ CT □ Endoscopy □ None

  • □ Other: Please specify

• 6. Do you discharge your patients on oral antibiotics?

  • □ Yes □ No

  • If yes, what is your choice of oral antibiotic(s) for how long? If you use combinations please indicate

• 7. What dietary advice do you give your patients on discharge?

  • □ Normal diet

  • □ Low residue diet

  • □ High fibre diet

  • □ Avoidance of nuts and seeds

  • □ Other: Please indicate

• 8. What other medications do you prescribe on discharge?

  • □ Laxatives

  • □ Stool-bulking agents

  • □ Antispasmodics

  • □ Other: Please indicate

• 9. How soon do you review these patients in your clinic after discharge?

  • □ 2 weeks □ 2–4 weeks

  • □ 4–8 weeks □ 8–12 weeks

• 10. What diagnostic investigation(s) do you request when your patient returns to the clinic?

  • □ Barium enema □ Sigmoidoscopy □ Colonoscopy

  • □ Ultrasound □ CT □ None

  • □ Other: Please indicate.

• 11. When will you consider elective resection in a patient with uncomplicated diverticulitis who is aged > 50 years after successful conservative management?

  • □ After 1 episode

  • □ After 2 episodes

  • □ After 3 or more episodes

  • □ Only when complications (i.e., fistula & stricture) arise

• 12. If your patient is young. i.e., younger than aged 50 years, when will you consider elective resection?

  • □ After 1 episode

  • □ After 2 episodes

  • □ After 3 or more episodes

  • □ Only when complications (i.e., fistula & stricture) arise