American Gastroenterological Association Institute Guidelines on the Management of Acute Diverticulitis

The American Gastroenterological Association (AGA) Institute has issued updated guidelines regarding the management of acute diverticulitis. Routine use of antibiotics in uncomplicated diverticulitis is not recommended, and selective use is more appropriate. Patients who have not had a recent colon exam require colonoscopy after an episode of acute diverticulitis to rule out the possibility of malignancy.

Patients with a history of acute diverticulitis may benefit from a fiber-rich diet or fiber supplementation, and do not need to avoid nuts, seeds, and popcorn. Patients with a history of acute diverticulitis may safely take aspirin but should avoid non-aspirin NSAIDs. Mesalamine, rifaximin, and probiotics all have no proven benefit after an episode of acute diverticulitis. Patients should be advised to exercise.

Recommendations

The AGA suggests:

• that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis.
• that colonoscopy be performed after resolution of acute diverticulitis in appropriate candidates to exclude the misdiagnosis of a colonic neoplasm if a high-quality examination of the colon has not been recently performed.
• against elective colonic resection in patients with an initial episode of acute uncomplicated diverticulitis. The decision to perform elective prophylactic colonic resection in this setting should be individualized.
• a fiber-rich diet or fiber supplementation in patients with a history of acute diverticulitis.
•  against routinely advising patients with a history of diverticulitis to avoid consumption of seeds, nuts, and popcorn.
• against routinely advising patients with a history of diverticulitis to avoid the use of aspirin.
• advising patients with a history of diverticulitis to avoid the use of nonaspirin NSAIDs if possible.
• against the use of mesalamine after acute uncomplicated diverticulitis.
• against the use of rifaximin after acute uncomplicated diverticulitis.
• against the use of probiotics after acute uncomplicated diverticulitis.
• advising patients with diverticular disease to consider vigorous physical activity.

Important discussion points:

• Antibiotics:
  Until recently, antibiotics have been the cornerstone of treatment of patients with acute diverticulitis. The emerging belief that acute diverticulitis may be more inflammatory than infectious, as well as increasing concerns about the overuse of antibiotics have led to the recommendation of selective and individualized antibiotic use. The current data are of low quality, and recommendations could change as further studies are performed. These recommendations should not be generalized to complicated patients (ie, those with abscesses or fistulas), those with signs of severe infection or sepsis, immunosuppressed patients, or patients with other significant comorbidities.
  Furthermore, outpatient management without antibiotics has not been studied.
• Colonoscopy:
  Observational studies of patients with imaging-proven diverticulitis who subsequently underwent colonoscopy detected a small number of colorectal cancers (15/1000 patients) and advanced adenomas (38/1000 patients). Absence of a mass lesion on CT scan does not exclude the possibility of an underlying colonic neoplasm. Evidence of alternative, non-neoplastic explanations for the index presentation, such as inflammatory bowel disease or ischemic colitis, was either infrequently identified or not reported. Although an increased risk of recurrent diverticulitis or colonic perforation is a concern in patients undergoing colonoscopy after an episode of acute diverticulitis, this was not reported as an adverse event.
• Elective Colonic Resection:
  Approximately 20% of patients with acute uncomplicated diverticulitis experience a recurrent episode of diverticulitis in the following 5 years. The risk of future diverticular complications and need for emergency surgery among patients treated medically without colonic resection is low (<5%). Approximately 10% of patients with elective sigmoid resection after an episode of acute diverticulitis experience short-term complications of surgery, including wound infection, anastomotic leak, and cardiovascular/thrombotic events. Such postoperative risks are increased in patients older than 65 years of age. Long-term complications of abdominal distention, cramping, altered defecation, and fecal incontinence are reported in 25% of patients after elective surgery. The rates of recurrent diverticulitis appear to be higher in younger patients and the operative risks are lower, but the data do not support elective surgery in this subgroup when presenting with acute uncomplicated diverticulitis.

In conclusion, the AGA states that the management of acute diverticulitis has undergone meaningful changes over the past decade, including more judicious use of antibiotics and surgery as well as preliminary and ongoing investigations into medical therapies to decrease symptoms and reduce recurrence.

http://www.gastro.org/guidelines

http://www.gastrojournal.org/article/S0016-5085(15)01432-8/abstract

http://www.gastrojournal.org/article/S0016-5085(15)01432-8/fulltext