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["Baseline assessment: diverticular disease: "]
["diagnosis and management"]
["NG147"]
[]
[]
["Published: 27 November 2019"]

{"sheet":"Introduction","index":1,"n_rows":12,"n_cols":1,"rows_kept":12,"cut":false,"hidden":false,"merged":[]}
["Baseline assessment tool for diverticular disease: diagnosis and management (NICE clinical guideline NG147)"]
["This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in diverticular disease: diagnosis and management.  It can also help to plan activity to meet the recommendations."]
["The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
["It should be used in conjunction with diverticular disease: diagnosis and management (NICE clinical guideline NG147)."]
["In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
["Is the guideline relevant?"]
[]
["The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
["The table can be adapted to include any other local information that is thought to be useful."]
["If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
["Tools and resources to help put the guidance into practice are available on the NICE website. "]
["National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2024. All rights reserved. Subject to Notice of rights.\n"]

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["Baseline assessment tool for diverticular disease: diagnosis and management (NICE clinical guideline NG147)"]
[]
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[]
["NICE recommendation","Guideline reference","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
["1.1 Diverticulosis"]
["Management and advice"]
["Tell people with diverticulosis that the condition is asymptomatic and no specific treatments are needed.","1.1.1"]
["Advise people to eat a healthy, balanced diet including whole grains, fruit and vegetables. Tell them that:\n•\tthere is no need to avoid seeds, nuts, popcorn or fruit skins\n•\tif they have constipation and a low-fibre diet, increasing their fibre intake gradually may minimise flatulence and bloating.","1.1.2"]
["Advise people to drink adequate fluid if they are increasing their fibre intake, especially if there is a risk of dehydration.","1.1.3"]
["Consider bulk-forming laxatives for people with constipation.","1.1.4"]
["Tell people about the benefits of exercise, and weight loss if they are overweight or obese, and stopping smoking, in reducing the risk of developing acute diverticulitis and symptomatic disease.","1.1.5"]
["1.2 Diverticular disease"]
["Symptoms and signs"]
["Suspect diverticular disease if a person presents with one or both of the following: \n•\tintermittent abdominal pain in the left lower quadrant with constipation, diarrhoea or occasional large rectal bleeds (the pain may be triggered by eating and relieved by the passage of stool or flatus)\n•\ttenderness in the left lower quadrant on abdominal examination.\nBe aware that: \n•\tin a minority of people and in people of Asian origin, pain and tenderness may be localised in the right lower quadrant \n•\tsymptoms may overlap with conditions such as irritable bowel syndrome, colitis and malignancy. ","1.2.1"]
["Investigations and referral"]
["Do not routinely refer people with suspected diverticular disease unless: \n•\troutine endoscopic and/or radiological investigations cannot be organised from primary care or\n•\tcolitis is suspected or\n•\tthe person meets the criteria for a suspected cancer pathway.","1.2.2"]
["If the person meets the criteria for a suspected cancer pathway, refer by this route (see NICE’s guideline on suspected cancer: recognition and referral).","1.2.3"]
["Management and advice"]
["Do not offer antibiotics to people with diverticular disease.","1.2.4"]
["Advise people to avoid non-steroidal anti-inflammatory drugs and opioid analgesia if possible, because they may increase the risk of diverticular perforation.","1.2.5"]
["For advice on diet, fluid intake, stopping smoking, weight loss and exercise, follow the recommendations in section 1.1 on diverticulosis.","1.2.6"]
["Advise people that:\n•\tthe benefits of increasing dietary fibre may take several weeks to achieve\n•\tif tolerated, a high-fibre diet should be maintained for life.","1.2.7"]
["Consider bulk-forming laxatives if: \n•\ta high-fibre diet is unacceptable to the person or it is not tolerated or \n•\tthe person has persistent constipation or diarrhoea.","1.2.8"]
["Consider simple analgesia, for example paracetamol, as needed if the person has ongoing abdominal pain.","1.2.9"]
["Consider an antispasmodic if the person has abdominal cramping.","1.2.10"]
["If the person has persistent symptoms or symptoms that do not respond to treatment, think about alternative causes and investigate and manage appropriately.","1.2.11"]
[" Recurrent diverticular disease"]
["The committee were unable to make recommendations for practice in this area."]
["1.3 Acute diverticulitis"]
["Symptoms and signs of acute diverticulitis"]
["Suspect acute diverticulitis if a person presents with constant abdominal pain, usually severe and localising in the left lower quadrant, with any of the following: \n•\tfever or\n•\tsudden change in bowel habit and significant rectal bleeding or passage of mucus from the rectum or\n•\ttenderness in the left lower quadrant, a palpable abdominal mass or distention on abdominal examination, with a previous history of diverticulosis or diverticulitis. \nBe aware that in a minority of people and in people of Asian origin, pain and tenderness may be localised in the right lower quadrant.","1.3.1"]
["Symptoms and signs of complicated acute diverticulitis"]
["Suspect complicated acute diverticulitis and refer for same-day hospital assessment if the person has uncontrolled abdominal pain and any of the features in table 1.","1.3.2"]
["Investigation of suspected acute diverticulitis"]
["Primary care"]
["For people with suspected uncomplicated acute diverticulitis who are not referred for same-day hospital assessment: \n•\treassess in primary care if their symptoms persist or worsen and \n•\tconsider referral to secondary care for further assessment.","1.3.3"]
["Secondary care"]
["For people with suspected complicated acute diverticulitis who have been referred for same-day hospital assessment, offer a full blood count, urea and electrolytes test and C‑reactive protein test.","1.3.4"]
["If the person with suspected complicated acute diverticulitis has raised inflammatory markers, offer a contrast CT scan within 24 hours of hospital admission to confirm diagnosis and help plan management. If contrast CT is contraindicated, perform one of the following: \n•\ta non-contrast CT or\n•\tan MRI or\n•\tan ultrasound scan, depending on local expertise. ","1.3.5"]
["If inflammatory markers are not raised, think about the possibility of alternative diagnoses.","1.3.6"]
["Non-surgical management of acute diverticulitis"]
["For people with acute diverticulitis who are systemically well: \n•\tconsider a no antibiotic prescribing strategy \n•\toffer simple analgesia, for example paracetamol\n•\tadvise the person to re present if symptoms persist or worsen.","1.3.7"]
["Offer an antibiotic prescribing strategy if the person with acute diverticulitis is systemically unwell, is immunosuppressed or has significant comorbidity.","1.3.8"]
["Offer oral antibiotics if the person with acute diverticulitis is systemically unwell but does not meet the criteria for referral for suspected complicated acute diverticulitis.","1.3.9"]
["Offer intravenous antibiotics to people admitted to secondary care with suspected complicated acute diverticulitis.","1.3.10"]
["Review intravenous antibiotics within 48 hours or after scanning if sooner (see recommendation 1.3.5) and consider stepping down to oral antibiotics where possible.","1.3.11"]
["If the person has CT-confirmed uncomplicated acute diverticulitis, review the need for antibiotics and discharge them depending on any co-existing medical conditions.","1.3.12"]
["When prescribing an antibiotic for suspected or confirmed acute diverticulitis, follow the advice in table 2.","1.3.13"]
["Emergency management of complicated acute diverticulitis"]
["When prescribing an antibiotic for suspected or confirmed complicated acute diverticulitis, follow the advice in table 2.","1.3.14"]
["Management of abscesses"]
["For people presenting in secondary care with complicated acute diverticulitis and suspected diverticular abscess, assess and manage in line with the NICE guideline on sepsis.","1.3.15"]
["Offer intravenous antibiotics to people with acute diverticulitis and suspected diverticular abscess.","1.3.16"]
["When prescribing an antibiotic for diverticular abscess, follow the advice in table 2.","1.3.17"]
["Offer a contrast CT scan to people with acute diverticulitis and suspected diverticular abscess. If contrast CT is contraindicated, perform one of the following:\n•\ta non-contrast CT or  \n•\tan MRI or\n•\tan ultrasound scan, depending on local expertise.","1.3.18"]
["Review intravenous antibiotics within 48 hours or after scanning if sooner and consider stepping down to oral antibiotics where possible.","1.3.19"]
["Use the scan results to guide treatment based on the size and location of the abscess.","1.3.20"]
["If a person does not have confirmed diverticular abscess, review their need for antibiotics.","1.3.21"]
["Consider either percutaneous drainage (if anatomically feasible) or surgery (see recommendation 1.3.27) for abscesses greater than 3 cm.","1.3.22"]
["Send samples of pus from the abscess (if it has been drained) to the microbiology laboratory to enable antibiotic treatment to be tailored to sensitivities.","1.3.23"]
["For abscesses less than 3 cm switch to oral antibiotics where possible.","1.3.24"]
["In people with a CT-confirmed diverticular abscess, if the condition does not improve clinically or there is deterioration, consider re-imaging to inform the management strategy.","1.3.25"]
["Management of bowel perforations"]
["Offer either laparoscopic lavage or resectional surgery (see recommendation 1.3.27) to people with diverticular perforation with generalised peritonitis after discussing the risks and benefits of the 2 options with them (see table 3). If faecal peritonitis is identified intraoperatively, proceed to resectional surgery.","1.3.26"]
["Anastomosis and bowel resection for people with complicated acute diverticulitis (elective and emergency surgery)"]
["Offer people with complicated acute diverticulitis who are having surgery (either elective or emergency): \n•\tprimary anastomosis (join in the bowel) with or without diverting stoma or \n•\tHartmann’s procedure (resection of the bowel with an end stoma). \nTake into account the person's age, any other conditions they have and how well they can carry out everyday activities (WHO performance status).","1.3.27"]
["In people undergoing bowel resection, consider resecting back to the compliant bowel (that is, bowel that is soft, unthickened and unaffected by inflammation).","1.3.28"]
["Elective surgical management after resolution of complicated acute diverticulitis"]
["Consider open or laparoscopic resection for elective surgery for people who have recovered from complicated acute diverticulitis but have continuing symptoms, for example in people with stricture or fistula.","1.3.29"]
["Timing of surgery for complicated acute diverticulitis"]
["The committee were unable to make recommendations for practice in this area. They made a recommendation for research on timing of surgery for complicated acute diverticulosis."]
["Management of recurrent acute diverticulitis"]
["Do not offer an aminosalicylate or antibiotics to prevent recurrent acute diverticulitis.","1.3.30"]
["1.4 Information"]
["Diverticulosis"]
["Give people with diverticulosis, and their families and carers where appropriate, verbal and written information on: \n•\tdiet and lifestyle \n•\tthe course of diverticulosis and the likelihood of progression\n•\tsymptoms that indicate complications or progression to diverticular disease.","1.4.1"]
["Diverticular disease"]
["Give people with diverticular disease, and their families and carers where appropriate, verbal and written information on:\n•\tdiet and lifestyle \n•\tthe course of diverticular disease and the likelihood of progression\n•\tsymptoms and symptom management \n•\twhen to seek medical advice.","1.4.2"]
["Acute diverticulitis"]
["Give people with acute diverticulitis, and their families and carers where appropriate, verbal and written information on: \n•\tdiet and lifestyle\n•\tthe course of acute diverticulitis and likelihood of complicated disease or recurrent episodes\n•\tsymptoms \n•\twhen and how to seek further medical advice\n•\tpossible investigations and treatments\n•\trisks of interventions and treatments, including antibiotic resistance, and how invasive these are\n•\trole of surgery and outcomes (postoperative bowel function and symptoms).","1.4.3"]

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["Table 1 Symptoms and signs that suggest complicated acute diverticulitis"]
["Symptom or sign","Possible complication "]
["Abdominal mass on examination or peri-rectal fullness on digital rectal examination","Intra-abdominal abscess"]
["Abdominal rigidity and guarding on examination","Bowel perforation and peritonitis"]
["Altered mental state, raised respiratory rate, low systolic blood pressure, raised heart rate, low tympanic temperature, no urine output or skin discolouration","Sepsis (see the NICE guideline on sepsis)"]
["Faecaluria, pneumaturia, pyuria or the passage of faeces through the vagina","Fistula into the bladder or vagina"]
["Colicky abdominal pain, absolute constipation (passage of no flatus or stool), vomiting or abdominal distention","Intestinal obstruction"]

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["Table 2: Antibiotics for adults aged 18 years and over with suspected or confirmed acute diverticulitis"]
["Choice","Antibiotic","Dosage and course length (a longer course may be needed based on clinical assessment. Continue antibiotics for up to 14 days in people with CT‑confirmed diverticular abscess)"]
["First-choice oral antibiotic for suspected or confirmed uncomplicated acute diverticulitis","Co‑amoxiclav","500/125 mg three times a day for 5 days"]
["Alternative first-choice oral antibiotics if penicillin allergy or co‑amoxiclav unsuitable","Cefalexin (caution in penicillin allergy) with metronidazole\nOr \nTrimethoprim with metronidazole\nOr \nCiprofloxacin (only if switching from IV ciprofloxacin with specialist advice) with metronidazole","Cefalexin: 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infection) for 5 days\nTrimethoprim: 200 mg twice a day for 5 days\nCiprofloxacin: 500 mg twice a day for 5 days\nSee the MHRA January 2024 advice for restrictions and precautions on using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.\nMetronidazole: 400 mg three times a day for 5 days"]
["First-choice intravenous antibiotics for suspected or confirmed complicated acute diverticulitis\nReview intravenous antibiotics within 48 hours or after scanning if sooner and consider stepping down to oral antibiotics where possible.","Co-amoxiclav\nOr\nCefuroxime with metronidazole \nOr\nAmoxicillin with gentamicin and metronidazole  \nOr\nCiprofloxacin (only in people with allergy to penicillins and cephalosporins) with metronidazole ","Co-amoxiclav: 1.2 g three times a day \nCefuroxime: 750 mg three or four times a day (increased to 1.5 g three or four times a day if severe infection)\nAmoxicillin: 500 mg three times a day (increased to 1 g four times a day if severe infection)\nGentamicin: Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum gentamicin concentration. Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2019).\nCiprofloxacin: 400 mg twice or three times a day\nSee the MHRA January 2024 advice for restrictions and precautions on using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.\nMetronidazole: 500 mg three times a day"]
["Alternative intravenous antibiotics\nReview intravenous antibiotics within 48 hours or after scanning if sooner and consider stepping down to oral antibiotics where possible.","Consult local microbiologist ","−"]
["See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and "]
["breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics. "]

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["Table 3: Factors to take into account when deciding whether to have lavage or resection for diverticular perforation with generalised peritonitis"]
["Factor","Laparoscopic lavage","Resectional surgery"]
["What the procedure involves","In diverticulitis this involves washing the abdominal cavity and colon using keyhole surgery.","The surgical removal of the diseased colon followed by either reattaching the remaining segments of the colon or forming an end stoma. "]
["Effect on quality of life","There was no significant difference in quality of life scores reported for lavage and surgery.","There was no significant difference in quality of life scores reported for lavage and surgery."]
["Mortality","Although there was some benefit seen in mortality for lavage, this evidence was very uncertain.","Although there was some benefit seen in mortality for lavage, this evidence was very uncertain."]
["Needing a stoma (where the bowel is connected surgically to an opening in the abdomen and stools are collected in a bag or pouch)","A stoma is not needed.","A stoma may be needed."]
["Pain","Less likely to relieve pain than resectional surgery.","More likely to relieve pain than lavage because the damaged bowel has been removed."]
["Recurrent diverticulitis","Fewer people had recurrent diverticulitis after surgery than after lavage because the diseased bowel is removed. However, the evidence was very uncertain.","Fewer people had recurrent diverticulitis after surgery than after lavage because the diseased bowel is removed. However, the evidence was very uncertain."]
["Needing more operations","Evidence comparing unplanned surgery with lavage showed that fewer people needed reoperations after surgery than after lavage.\nEvidence that included unplanned surgery and planned surgery (scheduled stoma reversal after resectional surgery) showed that fewer people needed reoperations after lavage.\nHowever, in both cases the evidence was very uncertain.","Evidence comparing unplanned surgery with lavage showed that fewer people needed reoperations after surgery than after lavage.\nEvidence that included unplanned surgery and planned surgery (scheduled stoma reversal after resectional surgery) showed that fewer people needed reoperations after lavage.\nHowever, in both cases the evidence was very uncertain."]
["Postoperative complications","There was no meaningful difference in the number of infections or in the need for further intervention between lavage and surgery. People who had surgery had a greater reduction in post-surgical abscesses than those who had lavage, but this evidence was of low quality. ","There was no meaningful difference in the number of infections or in the need for further intervention between lavage and surgery. People who had surgery had a greater reduction in post-surgical abscesses than those who had lavage, but this evidence was of low quality. "]