ACP releases inaugural guidelines for acute left-sided colonic diverticulitis
The ACP has released its first-ever guidelines for diagnosing, managing and preventing recurrence of acute left-sided colonic diverticulitis.
An estimated 5% to 10% of patients with diverticulosis may develop acute diverticulitis, with the risk increasing with age, according to the guideline authors. The incidence of acute diverticulitis appears to be rising, with right-sided colonic diverticulitis more prevalent in Asian countries and left-sided colonic diverticulitis more prevalent in Western countries.
In the U.S., there are about 200,000 hospitalizations due to acute left-sided colonic diverticulitis each year, the guideline authors wrote. The cost of annual hospitalizations linked to a principal diagnosis of acute diverticulitis have topped $8 billion in the U.S. in recent years.
Diagnosis and management
For the diagnosis and management of acute left-sided colonic diverticulitis, the ACP recommends:
- using abdominal CT scans to diagnose the condition in instances of diagnostic uncertainty;
- managing most patients in an outpatient setting; and
- initially managing “select” patients with supportive care without antibiotics.
The guideline authors said that “select” patients could be defined as those with acute left-sided colonic diverticulitis who are immunocompetent and have no evidence of systemic inflammatory response or immunosuppression, who are not medically frail, do not need hospitalization, and can follow up as an outpatient under medical supervision and societal and familial support.
George Abraham, MD, MPH, MACP, FIDSA, the president of ACP and a practicing internist, said in a video accompanying the guidelines’ release that “although the traditional management includes antibiotics, ACP’s review of the literature found that evidence did not support their use for uncomplicated diverticulitis and suggest treatment without the use of antibiotics.”
Preventing recurrence
About 8% to 36% of patients with acute left-sided colonic diverticulitis will experience recurrence at 1 to 10 years, according to the guideline authors. To help prevent recurrence, the ACP recommends referring patients for a colonoscopy after an episode of complicated left-sided colonic diverticulitis if they had not recently received one.
“ACP suggests that clinicians refer patients who have not had recent colonoscopy to get one so that colorectal cancer, while rare, can be ruled out for their symptoms,” Abraham said.
The ACP also recommends that clinicians:
- avoid the use of mesalamine to prevent recurrence; and
- talk to patients about the potential benefits, harms, costs and their preferences about utilizing elective surgery to prevent recurrent diverticulitis if it is “persistent or recurs frequently or complicated.”
Conversations about elective surgery should be a shared decision-making process with the patient, primary care physician, gastroenterologist and surgeon, Abraham said.
Of all the recommendations for diagnosing, managing and preventing recurrence of acute left-sided colonic diverticulitis, the only strong recommendation based on high-certainty evidence is the one that discourages prescribing mesalamine.
“Evidence reviewed showed mesalamine resulted in no difference in the risk of recurrent diverticulitis compared to placebo and may not improve symptoms,” Abraham said.
The inaugural guidelines, which were published in Annals of Internal Medicine, are based on a review of 78 papers, most of them with a moderate or high risk for bias. The cohorts in these articles tended to be in their 40s or older, and the percentage of men, when reported, ranged from 28% to 64%.
References:Qaseem A, et al. Ann Intern Med. 2022;doi:10.7326/M21-2710.
Qaseem A, et al. Ann Intern Med. 2022;doi:10.7326/M21-2711.
Perspective
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Diverticulitis presents as a spectrum of disease that can present from uncomplicated localized inflammation to microperforation with abscess to frank peritonitis requiring an emergency operation. The treatment of diverticulitis has evolved over the last several decades, including initial diagnostic and treatment strategies, follow-up endoscopic evaluation and surgical resection.
The recent guidelines by the ACP have evaluated emerging data in regarding the evaluation and treatment of acute left-sided diverticulitis. These guidelines call for use of CT imaging in cases where there is diagnostic ambiguity, as CT remains the best study for diverticulitis. CT will confirm the diagnosis of uncomplicated versus complicated disease, which is an important distinction in regard to treatment paradigm. In the setting of simple, uncomplicated and localized inflammation, patients can be treated in the outpatient setting if they are able to maintain oral hydration.
The routine use of antibiotics was previously considered standard management for uncomplicated left-sided diverticulitis. However, new data have emerged that suggests that in select patients, antibiotics may be excluded from the treatment paradigm. Multiple studies have demonstrated that omitting antibiotics does not correlate with worse outcomes regarding resolution of symptoms, recurrence and need for surgery. It is important to counsel patients regarding worrisome signs including worsening of abdominal pain, inability to tolerate a diet, or worsening fevers) that may suggest that outpatient management may be insufficient, signaling the need for inpatient management.
Following resolution of diverticulitis, these guidelines call for endoscopic evaluation with colonoscopy. This recommendation is especially important for patients who are not up to date on colorectal cancer screening. Colonoscopy does not have to be repeated after each episode but should be performed if there is any uncertainty regarding the diagnosis. In regard to surgical management, patients should be referred for surgical referral in the setting of: No. 1, smoldering disease that persists despite antibiotic treatment; No. 2, several episodes of recurrent diverticulitis (typically three or more); or No. 3, complicated disease (such as abscess, colonic fistula). Additionally, there is minimal evidence to suggest that mesalamine will prevent future attacks of diverticulitis.
I do agree with these recommendations, but they must be applied selectively. If there is any concern that a patient cannot stay hydrated as an outpatient, then they should be considered for admission to the hospital. Also, patients who may have several co-morbidities may be treated better in the hospital so that those co-morbidities can be managed simultaneously since the patient is not necessarily eating and drinking normally (eg, diabetes, heart failure and renal insufficiency).
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