Urgent Care Management of Diverticular Disease

Table of Contents

 

About This Issue

The prevalence of diverticular disease is on the rise as the population ages. Diverticular disease encompasses a spectrum of gastrointestinal conditions, primarily diverticulosis and diverticulitis, characterized by the formation of diverticula in the colon. The pathophysiology is caused by many factors: mechanical, microbiological, neuromuscular, genetic, environmental, and inflammatory. Diverticular disease presents with symptoms such as left lower quadrant abdominal pain, fever, nausea, and altered bowel habits that can overlap with other gastrointestinal conditions. In this issue, you will learn:

The etiology, pathophysiology, and risk factors of diverticular disease;

The conditions that comprise the differential diagnoses and how to differentiate diverticular disease from other gastrointestinal conditions and abdominal pain;

How a detailed history and thorough physical examination can help determine if additional diagnostic studies available in the urgent care setting are needed to diagnose the severity of a diverticular presentation;

The most current treatment and pain management recommendations; and

The disposition of patients with diverticular disease, including discharge instructions and preventive measures.

CODING & CHARTING: Accurate documentation of diverticular disease in urgent care supports clinical decisions, proper reimbursement, and quality care. Learn more in our monthly coding column.

1. Abstract
2. Case Presentations
3. Introduction
4. Etiology and Pathophysiology
5. Symptomatic Uncomplicated Diverticular Disease
6. Differential Diagnosis
   1. Infectious Colitis
   2. Irritable Bowel Syndrome
   3. Colorectal Cancer
   4. Inflammatory Bowel Disease
   5. Appendicitis
   6. Ischemic Colitis
   7. Gynecological Conditions
   8. Urologic Conditions
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
   3. Diagnostic Studies
      1. Laboratory Studies
      2. Imaging Studies
      3. Urgent Care Limitations and Referral
8. Treatment
   1. Symptomatic Uncomplicated Diverticular Disease
      1. Dietary Modifications
      2. Probiotics
      3. Pharmacological Therapy
      4. Management of Acute Symptoms
   2. Acute Diverticulitis
      1. Uncomplicated Acute Diverticulitis
      2. Complicated Acute Diverticulitis
   3. Diverticular Hemorrhage
9. Disposition
   1. Discharge Instructions and Preventive Measures
10. Special Populations
    1. Older Patients
    2. Pregnant and Postpartum Patients
    3. Immunocompromised Patients
    4. Pediatric Patients
11. Controversies and Cutting Edge
    1. The Role of Antibiotics in Uncomplicated Diverticulitis
    2. Dietary Recommendations
    3. Emerging Role of Microbiome-Based Therapies
    4. Personalized Medicine and Risk Stratification
12. Summary
13. Time- and Cost-Effective Strategies
14. Critical Appraisal of the Literature
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls in the Urgent Care Evaluation of Diverticular Disease
17. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
    2. Problems Addressed
    3. Complexity of Data
    4. Risk of Patient Management
    5. Documentation Tips
18. Coding Challenge: Managing Diverticular Disease in Urgent Care
19. Case Conclusions
20. Clinical Pathway for the Urgent Care Diagnosis and Treatment of Diverticular Disease
21. References

Abstract

Diverticular disease encompasses a spectrum of gastrointestinal conditions (but primarily diverticulosis and diverticulitis), which together affect a large proportion of the adult population, particularly people aged >40 years. Effective diagnosis and management of diverticular disease are crucial to minimizing complications and improving patient outcomes. Advancements in diagnostic imaging and the development of more refined treatment strategies have made it possible to manage diverticulitis more effectively. This issue reviews colonic diverticular disease, exploring the etiology, pathophysiology, and clinical management in the urgent care setting. Emphasis is placed on evidence-based approaches, emerging trends in treatment, and the critical role of early intervention in preventing serious complications.

Case Presentations

A 50-year-old woman presents to the urgent care clinic with a 2-day history of left lower quadrant pain, low-grade fever, and nausea…

• She denies any significant changes in bowel habits but reports mild bloating.
• Her medical history is unremarkable. She denies recent travel or antibiotic use.
• On examination, she has stable vital signs, including a temperature of 100.4°F. Localized tenderness is noted in the left lower quadrant without rebound or guarding.
• You wonder whether any additional testing is needed…

A 68-year-old man with a history of type 2 diabetes and hypertension presents to urgent care with severe abdominal pain, fever, and vomiting that started 3 days ago…

• His symptoms have progressively worsened.
• On examination, he appears acutely ill, with a temperature of 101.5°F, and exhibits signs of peritonitis, including abdominal rigidity and guarding.
• You wonder if this patient should be hospitalized or advanced interventions are warranted…

A 42-year-old woman presents to urgent care with recurrent left lower quadrant pain, mild bloating, and constipation…

• She has a history of diverticulosis, diagnosed incidentally on colonoscopy 5 years ago.
• Vital signs are stable, and the physical examination is unremarkable.
• You consider the best course of action for managing her symptomatic uncomplicated diverticular disease and wonder whether any further interventions are necessary…

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Clinical Pathway for Managing Patients Presenting with Acute Diarrhea in Urgent Care

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Tursi A. Diverticulosis today: unfashionable and still under-researched. Therap Adv Gastroenterol. 2016;9(2):213-228. (Review) DOI: 10.1177/1756283X15621228

2. * Tursi A, Papa A, Danese S. Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Aliment Pharmacol Ther. 2015;42(6):664-684. (Review) DOI: 10.1111/apt.13322

7. * Carabotti M, Annibale B, Severi C, et al. Role of fiber in symptomatic uncomplicated diverticular disease: a systematic review. Nutrients. 2017;9(2). (Systematic review; 12 studies) DOI: 10.3390/nu9020161

8. * Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology. 2019;156(5):1282-1298 e1281. (Review) DOI: 10.1053/j.gastro.2018.12.033

11. * Hullar MA, Sandstrom R, Lampe JW, et al. The fecal microbiome differentiates patients with a history of diverticulitis vs those with uncomplicated diverticulosis. Gastroenterology. 2017;152(5):S1. (Cross-sectional analysis; 98 patients) DOI: 10.1016/S0016-5085(17)32217-5

12. * Tursi A, Mastromarino P, Capobianco D, et al. Assessment of fecal microbiota and fecal metabolome in symptomatic uncomplicated diverticular disease of the colon. J Clin Gastroenterol. 2016;50 Suppl 1:S9-S12. (Case-control study; 66 patients) DOI: 10.1097/MCG.0000000000000626

18. * Waugh N, Cummins E, Royle P, et al. Faecal calprotectin testing for differentiating amongst inflammatory and non-inflammatory bowel diseases: systematic review and economic evaluation. Health Technol Assess. 2013;17(55):xv-xix, 1-211. (Systematic review; 19 studies) DOI: 10.3310/hta17550

21. * Tursi A. A critical appraisal of advances in the diagnosis of diverticular disease. Expert Rev Gastroenterol Hepatol. 2018;12(8):791-796. (Critical review) DOI: 10.1080/17474124.2018.1487288

33. * Rottier SJ, van Dijk ST, Unlu C, et al. Complicated disease course in initially computed tomography-proven uncomplicated acute diverticulitis. Surg Infect (Larchmt). 2019;20(6):453-459. (Observational study; 1087 patients) DOI: 10.1089/sur.2018.289

47. * van Dijk ST, Daniels L, Unlu C, et al. Long-term effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol. 2018;113(7):1045-1052. (Randomized controlled trial; 528 patients) DOI: 10.1038/s41395-018-0030-y

52. * Stollman N, Smalley W, Hirano I. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149(7):1944-1949. (Guideline) DOI: 10.1053/j.gastro.2015.10.003

54. * Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Gastroenterology. 2021;160(3):906-911. (Review) DOI: 10.1053/j.gastro.2020.09.059

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Keywords: colonic diverticular disease, diverticular disease, diverticula, diverticulitis, diverticulosis, microbiome, gut microbiota, computed tomography, colon, sigmoid colon, symptomatic uncomplicated diverticular disease (SUDD), C-reactive protein, probiotic, gastrointestinal, colonic pressure, dysbiosis, procalcitonin, uncomplicated acute diverticulitis, complicated acute diverticulitis, diverticular hemorrhage, dietary interventions