A new clinical practice update from the American Gastroenterological Association seeks to provide gastroenterologists with practical and evidence-based advice for management of colonic diverticulitis.
Dr. Anne F. Peery
For example, clinicians should consider lower endoscopy and CT scans of the abdomen and pelvis with oral and intravenous contrast to rule out chronic diverticular inflammation, diverticular stricture or fistula, ischemic colitis, constipation, and inflammatory bowel disease, Anne F. Peery, MD, MSCR, of the University of North Carolina, Chapel Hill, and associates wrote in Gastroenterology.
“In our practice, patients are reassured to know that ongoing symptoms are common and often attributable to visceral hypersensitivity,” they wrote. “This conversation is particularly important after a negative workup. If needed, ongoing abdominal pain can be treated with a low to modest dose of a tricyclic antidepressant.”
The update from the AGA includes 13 other recommendations, with noteworthy advice to use antibiotics selectively, rather than routinely, in cases of acute uncomplicated diverticulitis in immunocompetent patients. In a recent large meta-analysis, antibiotics did not shorten symptom duration or reduce rates of hospitalization, complications, or surgery in this setting. The clinical practice update advises using antibiotics if patients are frail or have comorbidities, vomiting or refractory symptoms, a C-reactive protein level above 140 mg/L, a baseline white blood cell count above 15 × 109 cells/L, or fluid collection or a longer segment of inflammation on CT scan. Antibiotics also are strongly advised for immunocompromised patients, who are at greater risk for complications and severe diverticulitis. Because of this risk, clinicians should have “a low threshold” for cross-sectional imaging, antibiotic treatment, and consultation with a colorectal surgeon, according to the update.
The authors recommend CT if patients have severe symptoms or have not previously been diagnosed with diverticulitis based on imaging. Clinicians also should consider imaging if patients have had multiple recurrences, are not responding to treatment, are immunocompromised, or are considering prophylactic surgery (in which case imaging is used to pinpoint areas of disease).
Colonoscopy is advised after episodes of complicated diverticulitis or after a first episode of uncomplicated diverticulitis if no high-quality colonoscopy has been performed in the past year. This colonoscopy is advised to rule out malignancy, which can be misdiagnosed as diverticulitis, and because diverticulitis (particularly complicated diverticulitis) has been associated with colon cancer in some studies, the update notes. Unless patients have “alarm symptoms” – that is, a change in stool caliber, iron deficiency anemia, bloody stools, weight loss, or abdominal pain – colonoscopy should be delayed until 6-8 weeks after the diverticulitis episode or until the acute symptoms resolve, whichever occurs later.
The decision to discuss elective segmental resection should be based on disease severity, not the prior number of episodes. Although elective surgery for diverticulitis has become increasingly common, patients should be aware that surgery often does not improve chronic gastrointestinal symptoms, such as abdominal pain, and that surgery reduces but does not eliminate the risk for recurrence. The authors recommended against surgery to prevent complicated diverticulitis in immunocompetent patients with a history of uncomplicated episodes. “In this population, complicated diverticulitis is most often the first presentation of diverticulitis and is less likely with recurrences,” the update states. For acute complicated diverticulitis that has been effectively managed without surgery, patients are at heightened risk for recurrence, but “a growing literature suggest[s] a more conservative and personalized approach” rather than the routine use of interval elective resection, the authors noted. For all patients, counseling regarding surgery should incorporate thoughtful discussions of immune status, values and preferences, and operative risks versus benefits, including effects on quality of life.
Dr. Peery and another author were supported by grants from the National Institutes of Health. The authors reported having no conflicts of interest.
SOURCE: Peery AF et al. Gastroenterology. 2020 Dec 3. doi: 10.1053/j.gastro.2020.09.059.
This article was updated Feb. 10, 2021.