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History
Presenting symptoms and context
Diverticulitis concern history framework
Left lower quadrant abdominal pain
Prior diverticulitis episodes
Prior CT confirmed diverticulitis
Recent antibiotics
Recent colonoscopy and findings
Recent constipation or diarrhea
Recent change in bowel habits
Recent travel
Recent sick contacts
OPQRST
OPQRST for abdominal pain
Onset
Time of onset
Sudden onset
Gradual onset
Provocation and palliation
Worse with movement
Worse with meals
Worse with bowel movement
Relief with bowel movement
Relief with antispasmodic
Quality
Cramping
Sharp
Constant
Region and radiation
Left lower quadrant
Suprapubic
Right sided pain
Flank radiation
Severity
Pain score
Functional limitation
Timing
Progressive worsening
Intermittent
Recurrent similar episodes
Associated symptoms
Associated symptoms cluster
Fever
Chills
Nausea
Vomiting
Anorexia
Constipation
Diarrhea
Hematochezia
Melena
Dysuria
Urinary frequency
Pneumaturia
Fecaluria
Vaginal discharge
Vaginal bleeding
Special populations history
Population modifiers
Pregnancy possibility
Immunocompromised status
Chronic kidney disease
Older adult frailty
Anticoagulation use
Alarm Features
Immediate escalation triggers
Time critical red flags
Peritonitis on exam
Hypotension or shock
New altered mental status
Persistent vomiting with dehydration
Severe uncontrolled pain
Concern for perforation
Vital sign danger thresholds
Vital sign threats
Systolic blood pressure less than 90 mmHg
Heart rate 120 or higher
Respiratory rate 22 or higher
Temperature 38.0 C or higher with systemic toxicity
Oxygen saturation less than 92 percent on room air
High risk historical features
High risk history patterns
Immunosuppression
Recent chemotherapy
Solid organ transplant
Chronic high dose steroids
Recent intra abdominal surgery
Known colorectal cancer
Inflammatory bowel disease
High risk exam findings
High risk abdominal findings
Guarding
Rigidity
Rebound tenderness
Marked abdominal distension
Localized mass with toxicity
Medications
Current medications and interactions
Medication review for diverticulitis pathways
Anticoagulants
Antiplatelets
NSAIDs
Systemic steroids
Immunosuppressants
SGLT2 inhibitors
Opioids
Recent antibiotics
Antibiotic contraindications and cautions
Antibiotic safety screen
Penicillin allergy phenotype
QT prolongation risk
Tendinopathy risk with fluoroquinolones
C difficile history
Drug interactions with warfarin
Symptom control medication exposure
Recent symptom control agents
Laxatives
Antidiarrheals
Antispasmodics
Antiemetics
Diet
Recent intake and hydration
Diet and hydration status
Poor oral intake
Fluid intake reduction
Signs of dehydration
Diet patterns relevant to diverticular disease
Diet patterns
Low fiber baseline diet
Recent fiber increase
Recent constipation trigger foods
Substance exposures
Substance exposures
Alcohol intake pattern
Cannabis hyperemesis features
High caffeine intake
Review of Systems
Constitutional and infectious
Infection and inflammation screen
Fever
Chills
Night sweats
Weight loss
Gastrointestinal
GI symptom screen
Abdominal pain location pattern
Nausea
Vomiting
Constipation
Diarrhea
Hematochezia
Melena
Tenesmus
Genitourinary and gynecologic
GU and pelvic symptom screen
Dysuria
Hematuria
Urgency
Flank pain
Vaginal bleeding
Vaginal discharge
Dyspareunia
Cardiopulmonary and neuro
Systems that shift risk
Chest pain
Dyspnea
Syncope
Confusion
Collateral History and Family History
Collateral and reliability
Collateral context
Source
Reliability concerns
Family history relevant to alternate diagnoses
Family history
Colorectal cancer family history
Inflammatory bowel disease family history
Exposure and support context
Social context
Ability to obtain medications
Ability to return for reassessment
Home support
Risk Factors
Diverticulitis and complication risk
Diverticulitis risk modifiers
Prior complicated diverticulitis
Known diverticulosis
Prior abscess
Prior fistula
Infection and severe disease risk
Severe infection risk
Immunocompromised state
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Cirrhosis (K74.60)
Bleeding and medication related risk
Medication related risk
Anticoagulation use
Antiplatelet use
NSAID exposure
Differential Diagnosis
Life threatening
Life threatening abdominal diagnoses
Perforated viscus
Sudden severe pain
Peritonitis
Sepsis from intra abdominal source
Hypotension
Lactate elevation
Mesenteric ischemia
Pain out of proportion
Atrial fibrillation history
Ruptured abdominal aortic aneurysm
Older age
Back pain with hypotension
Bowel obstruction
Obstipation
Vomiting
Common
Common causes of left lower quadrant pain
Acute uncomplicated diverticulitis (K57.32)
LLQ pain with tenderness
Low grade fever possible
Ureterolithiasis (N20.0)
Colicky flank pain
Hematuria
Urinary tract infection (N39.0)
Dysuria
Pyuria
Gastroenteritis
Prominent diarrhea
Sick contacts
Constipation
Reduced stool output
Stool burden on imaging
Less common and mimics
Less common and mimics
Colorectal cancer (C18.9)
Weight loss
Iron deficiency anemia
Inflammatory bowel disease
Chronic diarrhea
Extraintestinal manifestations
Ischemic colitis (K55.9)
Crampy pain with hematochezia
Vascular risk factors
Gynecologic pathology
Ectopic pregnancy (O00.9)
Ovarian torsion (N83.519)
PID (N73.9)
Epiploic appendagitis
Localized pain
Minimal systemic symptoms
Past Medical History
Relevant diagnoses and prior episodes
Past history anchors
Diverticulosis
Prior diverticulitis episodes
Prior complicated diverticulitis
Prior C difficile infection
Prior procedures and surgeries
Procedures and operations
Prior colonoscopy date and findings
Prior bowel resection
Prior appendectomy
Baseline function and frailty
Baseline status
Functional independence
Long term care residence
Frailty indicators
Physical Exam
General and vitals interpretation
General assessment
Toxic appearance
Hydration status
Pain behavior
Abdominal exam
Abdominal findings
Location of maximal tenderness
Guarding
Rigidity
Rebound tenderness
Palpable mass
Distension
Bowel sounds abnormal
Cardiopulmonary
Cardiopulmonary findings
Tachycardia pattern
Lung findings for pneumonia mimic
Genitourinary and pelvic
GU and pelvic exam targets
CVA tenderness
Pelvic exam indications
Testicular exam indications
Skin and extremities
Perfusion and rash checks
Mottling
Capillary refill delay
Rash suggesting vasculitis
Rectal exam considerations
Rectal exam decision points
GI bleeding concern
Severe constipation concern
Lab Studies
Core labs and severity markers
ED lab bundle for suspected diverticulitis
CBC
Leukocytosis support for inflammation
WBC greater than 15 x 10^9 per L as higher risk marker
Electrolytes and creatinine
Dehydration assessment
Contrast safety planning
CRP if available
CRP greater than 140 mg per L as higher risk marker
Uses as adjunct not sole rule out
Venous lactate
Sepsis marker
Lactate 2 mmol per L or higher supports hypoperfusion
Pregnancy and urinary testing
Pregnancy and urine testing
Urine pregnancy test
Rule out ectopic pregnancy in reproductive age
Imaging choice modifier
Urinalysis
UTI mimic
Hematuria for stone mimic
Blood cultures and advanced testing
Infection workup escalation
Blood cultures if sepsis physiology
Type and screen if GI bleeding concern
Pitfalls and limitations
Lab limitations
Normal WBC does not exclude diverticulitis
CRP low does not exclude early disease
Imaging
Scoring Systems
CT based severity frameworks
WSES CT classification
Uncomplicated disease category
Complicated disease categories
Hinchey classification use after CT or operative findings
Abscess local
Purulent peritonitis
Feculent peritonitis
MRI
MRI considerations
Pregnancy when ultrasound non diagnostic and CT avoidance preferred
Contrast contraindication scenarios
Limitations
Availability in ED
Motion artifact with pain
CT
CT abdomen pelvis pathway
Indications
First episode with diagnostic uncertainty
Severe symptoms
Concern for complications
Protocol notes
IV contrast preferred when renal function permits
Oral contrast local protocol dependent
Interpretation targets
Colonic wall thickening
Pericolic fat stranding
Abscess size
Free air
Obstruction
Fistula
Contrast cautions
CKD risk assessment
Prior contrast reaction history
Ultrasound
Ultrasound roles
Pregnancy and gynecologic evaluation
RUQ ultrasound if biliary mimic
POCUS adjuncts
Hydronephrosis for stone mimic
Free fluid if peritonitis concern
Limitations
Reduced sensitivity for diverticulitis in obesity
Operator dependence
Special Tests
Bedside clinical pathways
Bedside severity assessment
Sepsis screening
Serial abdominal exams
Pain trajectory after analgesia
Procedural diagnostics when indicated
Focused exams when alternative diagnosis suspected
Pelvic exam
Point of care pregnancy testing
Stool testing only with prominent diarrhea
Consultation triggered testing
Specialty directed testing
Interventional radiology planning for abscess drainage
Surgical evaluation for peritonitis
ECG
When ECG matters in abdominal presentations
ECG indications
Older patient with epigastric pain
Chest discomfort or dyspnea
Hypotension or syncope
High risk ECG findings that change disposition
ECG red flags
STEMI pattern
New ischemic ST segment changes
New high grade AV block
Assessment
Working diagnosis and severity
Working diagnosis structure
Acute uncomplicated diverticulitis (K57.32)
Localized LLQ tenderness
Stable vitals
Acute diverticulitis with abscess (K57.20 or K57.21 local coding dependent)
CT abscess present
Persistent fever or leukocytosis
Perforated diverticulitis with peritonitis
Free air
Diffuse peritonitis
Risk stratification
Higher risk features supporting antibiotics or admission
Immunocompromised state
Frailty or major comorbidity burden
Refractory symptoms
Vomiting limiting oral intake
CRP greater than 140 mg per L
WBC greater than 15 x 10^9 per L
CT fluid collection
Long segment inflammation on CT
Complications to rule out
Complication checklist
Abscess
Obstruction
Fistula
Free perforation
Sepsis
Plan
First 5 minutes and stabilization
Critical patient workflow
Continuous monitoring if sepsis physiology
IV access criteria
Two large bore IV if hypotension or lactate elevation
One IV acceptable if stable and outpatient pathway likely
Fluids
Balanced crystalloid bolus 10 to 20 mL per kg if hypovolemia
Reassess after each bolus
If septic shock then early antibiotics and source control pathway
Diagnostic sequencing
Diagnostic plan
Pregnancy test before CT in reproductive age when relevant
CT abdomen pelvis if first episode or complication concern
Surgical consult if peritonitis or free air
Analgesia and symptom control
Symptom control
Acetaminophen 1000 mg PO every 6 hours as needed
Maximum 4000 mg per day
Lower maximum in liver disease
Ibuprofen 400 mg PO every 6 to 8 hours as needed
Avoid in CKD
Avoid in active GI bleeding
Hydromorphone 0.5 mg IV every 10 to 15 minutes as needed for severe pain
Monitor respiratory status
Transition to PO when stable
Ondansetron 4 mg IV or PO every 8 hours as needed
QT prolongation caution
Antibiotics and source control
Antibiotic strategy aligned to severity and host factors
Uncomplicated and immunocompetent mild disease
No antibiotics option with reliable follow up
Close reassessment within 48 to 72 hours
Antibiotics advised when higher risk features present
Comorbidities or frailty
Refractory symptoms or vomiting
CRP greater than 140 mg per L
WBC greater than 15 x 10^9 per L
CT fluid collection
Complicated diverticulitis
Outpatient antibiotic examples local protocol dependent
Amoxicillin clavulanate 875 mg and 125 mg PO twice daily for 4 to 7 days
Co amoxiclav 500 mg and 125 mg PO three times daily for 5 days
If penicillin allergy then alternative regimen per local protocol
Inpatient antibiotic examples local protocol dependent
Ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours
Piperacillin tazobactam 4.5 g IV every 6 hours
Abscess management
Percutaneous drainage pathway for larger abscesses
Surgery if generalized peritonitis or failure of non operative management
Nutrition and bowel regimen
Diet plan by severity
Clear liquids for 24 to 48 hours if nausea prominent
Advance diet as pain improves
Avoid routine bowel rest in stable mild disease
Reassessment loop
Reassessment schedule
Repeat vitals after analgesia and fluids
Repeat abdominal exam within 60 to 90 minutes
Escalate to CT or consult if worsening pain or new peritonitis
Disposition
ICU criteria
ICU triggers
Septic shock requiring vasopressors
Lactate 4 mmol per L or higher with clinical instability
Need for invasive ventilation
Inpatient admission criteria
Admission indications
Complicated diverticulitis on CT
Abscess requiring IV antibiotics or drainage
Free air or peritonitis
Inability to tolerate oral intake
Uncontrolled pain requiring IV opioids
Immunocompromised state
Unreliable follow up or unsafe home setting
Observation and outpatient criteria
Outpatient pathway criteria
Hemodynamic stability
No peritonitis
Oral intake adequate
Pain controlled with PO meds
Reliable follow up within 48 to 72 hours
Clear return precautions understood
Observation pathway criteria
Borderline oral tolerance improving with ED therapy
Diagnostic uncertainty awaiting CT results
Discharge Instructions
Copy discharge instructions
Discharge instruction text
You were treated for suspected or confirmed diverticulitis
This is inflammation of small pouches in the colon and can cause left sided lower abdominal pain and fever
Take medications exactly as prescribed
If antibiotics were prescribed then finish the full course unless told otherwise by your clinician
Use acetaminophen as directed for pain
Avoid NSAIDs if you were told you have kidney disease stomach ulcers or bleeding risk
Drink fluids regularly
Start with a light diet and advance as pain and nausea improve
Follow up with your primary care clinician within 2 to 3 days
Gastroenterology or surgery follow up may be needed based on CT results
Return to the emergency department now for
Worsening abdominal pain
New severe abdominal tenderness
Persistent vomiting or inability to drink fluids
Fever not improving
Dizziness fainting or weakness
Blood in stool or black stool
References
Guidelines and high quality sources
Evidence base for acute diverticulitis management
American Gastroenterological Association Clinical Practice Update on Medical Management of Colonic Diverticulitis 2021
World Society of Emergency Surgery WSES guidelines update for acute colonic diverticulitis 2020
American Society of Colon and Rectal Surgeons Clinical Practice Guidelines Treatment of Left Sided Colonic Diverticulitis 2020
NICE Diverticular disease antimicrobial prescribing visual summary updated September 2024
NICE Diverticular disease diagnosis and management NG147 2019
Project instructions
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.