The scenarios are fictitious but similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could be also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid. 

Icon used to indicate Guidelines in Practice test and reflect content

The following case studies, written by Dr Michael Sproat relate to his expert article, Key learning points: NICE diverticular disease. In his article, Dr Sproat identifies five key learning points for primary care from the 2019 NICE guideline on the diagnosis and management of diverticular disease.

Case 1: Trevor, 55 years old

Context

Trevor is fit and well. He was recently invited to have a routine flexible sigmoidoscopy as part of the national NHS bowel cancer screening programme. The test went well, but he was concerned to be told afterwards that it showed signs of sigmoid diverticulosis as he has read that this is a serious condition.

Questions for reflection

  1. What additional questions would you ask?
  2. What is the main advice that we should give Trevor?
  3. Is any follow up required?

Reveal how to manage this patient

Diverticulosis is a common finding at flexible sigmoidoscopy and it is hoped that the patient would have been appropriately counselled by the Endoscopy team regarding any findings seen. Use of the term ‘diverticulosis’ implies that he is asymptomatic but we should check if he experiences any abdominal pain, bloating, or an irregular bowel habit.

Lifestyle advice should be given as outlined in Box 2 (see article) with encouragement to follow a higher fibre diet, particularly if he has a tendency towards constipation. If necessary, a regular fibre supplement such as ispaghula husk may also be appropriate.

We can reassure Trevor that the chances of him developing significant symptoms in the future are low and no routine follow up is advised. In encouraging him to follow a higher fibre diet, however, it is recognised that some individuals may experience bloating and/or abdominal discomfort as a result and if this occurs he should seek additional advice.

Case 2: Sarah, 52 years old

Context

Sarah presents with a 6-month history of intermittent left lower abdominal discomfort. She also describes bloating and comments that her bowel habit has become more irregular of late. There is no rectal bleeding or unexplained weight loss.

Questions for reflection

  1. What additional tests should be considered?
  2. If diverticular disease is confirmed, what management is recommended?

Reveal how to manage this patient

The priority in patients presenting with new onset abdominal pain or change in bowel habit is to exclude serious causes, in particular cancer. With that in mind, recommended blood tests include serum CA125 in women aged over 50 years in respect of possible ovarian cancer (NICE Clinical Guideline 122), alongside full blood count (FBC), C-reactive protein (CRP), and coeliac serology testing.

In addition, we would want to exclude bowel cancer as a possible cause. NICE Guideline 12/Diagnostics Guidance 30 recommends the use of a faecal immunochemical test (FIT) stool sample in patients 50–60 years old with abdominal pain and/or change in bowel habit in the absence of weight loss or rectal bleeding. In younger patients, a faecal calprotectin stool test may also be appropriate to exclude inflammatory bowel disease/ colitis (NICE Diagnostics Guidance 11).

Direct referral for colonoscopy may be more appropriate if there is a higher clinical suspicion of colorectal cancer, particularly in the presence of unexplained weight loss, rectal bleeding, or a strong family history of colorectal cancer. Colonoscopy would also be indicated if other tests are abnormal, such as iron deficiency anaemia or a positive FIT.

Alternatively, if an individual has mild symptoms and initial baseline blood and stool tests (as above) are normal, it is debatable whether a colonoscopy is always required. In Sarah’s case, for example, it is possible that a working diagnosis might be made of irritable bowel syndrome, and while diverticular disease cannot be excluded, the treatment of both conditions might be very similar: for example the trial of a regular fibre supplement, paracetamol, and/or an antispasmodic such as mebeverine hydrochloride or hyoscine butylbromide. Indeed, if symptoms then settle colonoscopy may not then alter Sarah’s clinical management. In practice, however, it remains very likely that any older individual presenting with the new onset abdominal discomfort and/or an irregular bowel habit will be referred for colonoscopy, especially if symptoms do not settle and clinical uncertainty regarding the exact diagnosis persists, even if initial rule-out investigations such as FIT are negative.

Case 3: Monica, 72 years old

Context

Monica tells you that she was diagnosed 2 years ago with acute diverticulitis following investigations for a variable bowel habit and intermittent left-sided abdominal pain. She presents to your GP practice today following a 24-hour flare-up of her usual abdominal pain and requests a prescription for antibiotics.

She adds that these have been issued before on a number of occasions to good effect. She denies any rectal bleeding or acute change in bowel habit.

Questions for reflection

  1. What are your initial thoughts in terms of the history and diagnosis?
  2. What management do you recommend? Why?

Reveal how to manage this patient

Monica very clearly reports that she has acute diverticulitis, but the history above sounds much more like diverticular disease. This might be further supported if Monica has not previously required acute hospital admission, and/or if blood tests taken at the time of previous flare ups have included a normal FBC and CRP.

In terms of Monica’s current symptoms, it is important to clarify whether her pain is constant or intermittent, and if there is any suggestion of a temperature or fever. Examination should also assess for the presence of any signs of sepsis, abdominal guarding, rigidity, or mass.

If further history and examination is indeed suggestive of diverticular disease rather than acute diverticulitis, Monica should be encouraged to try paracetamol and/or an antispasmodic such as mebeverine hydrochloride or hyoscine butylbromide, which it is hoped will allow her pain to settle.

Even if mild, uncomplicated acute diverticulitis is suspected, the clinician should explain to Monica that antibiotics are often not required if an individual is systemically well and does not have any other medical problems that increase her risk of infection. In practice, however, it is recognised that Monica’s personal experience is that antibiotics have been helpful, and although this may be coincidental, a deferred prescription of co-amoxiclav (or alternative in the case of penicillin allergy, see Table 2 in article) may be appropriate if there is no response to antispasmodics. Clear safety netting and guidance on the need for further review would be necessary in case her condition did not improve.

Equally, if there remains uncertainty about the possibility of significant acute diverticulitis, or if Monica’s pain is poorly controlled, same-day hospital assessment is advised. A normal FBC and CRP would point to a more likely diagnosis of diverticular disease. If inflammatory markers are raised, a CT scan can be performed to exclude complicated disease such as an abscess or perforation.

Case 4: Sanjay, 42 years old

Context

Sanjay attends with a 48-hour history of acute right‑sided abdominal pain. This is poorly controlled despite the regular use of over-the-counter analgesia. He describes some mild diarrhoea but no rectal bleeding or vomiting. On examination he is alert but in obvious discomfort. There is tenderness throughout the right side of the abdomen but no guarding or rigidity.

He has a temperature of 38.1°C, blood pressure of 142/88 mmHg, pulse of 108 beats per minute, respiratory rate of 22 breaths per minute, and oxygen saturation of 98%.

Questions for reflection

  1. What conditions should be considered in Sanjay’s case?
  2. What management is advised?

Reveal how to manage this patient

The differential diagnosis in Sanjay’s case is potentially very wide and includes, but is not limited to, infective gastroenteritis, acute appendicitis, acute cholecystitis, colitis (ileo-colonic Crohn’s disease), ureteric colic, or ascending urinary tract infection.

Sanjay’s case is highlighted here for two reasons. Firstly, because in recent years there has been a significant increase in the reported incidence of acute diverticulitis in younger age groups, which should therefore be considered when patients are assessed. The second reason is that individuals from families of Asian origin are more likely to develop diverticula in the proximal large bowel and therefore present with right-sided pain.

When Sanjay is seen at the GP practice, the cause of his symptoms is unclear. He also has poorly controlled pain and signs of possible sepsis (National Early Warning Score [NEWS] score 4). Same-day hospital assessment is advised, including blood tests (such as urea and electrolytes [U&Es], liver function tests [LFTs], FBC and CRP), urinalysis, stool microscopy, culture and sensitivity [MC&S] and additional imaging to clarify the diagnosis and guide further management.