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American Gastroenterological Association Institute Guidelines on the Management of Acute Diverticulitis

November 7, 2015 5:20 PM

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

Diverticular Disease – A Common Problem

April 21, 2013 7:14 PM

By Dr. Michael Sossenheimer 

Diverticulosis is a common colonic finding. Diverticulosis refers to the presence of diverticula, while the term Diverticulitis implies inflammation of these diverticula. Unrecognized or untreated diverticulitis can cause abscesses or fistula formation, bowel obstruction, or even perforation. A diverticulum is a protrusion of colonic mucosa and submucosa, herniating through the colonic muscle layer, thereby only covered by serosa. Such herniation/protrusion occurs at weak points in the bowel wall where blood vessels penetrate.

The prevalence of diverticular disease increases with age (< 20% at age 40, >60% by age 60), and diverticular disease shows equal sex distribution or a slight female predominance. Most patients have sigmoid involvement, while a third also have more proximal disease. An overall observed increase in diverticulosis suggests an environmental or lifestyle effect, as a decreasing dietary fiber intake due to a westernized diet and sedentary lifestyle, both seemingly predisposing patients to the development of diverticular disease. As such, diverticulosis is less common in vegetarians and more likely in obese patients with a diet high in fat and red meat intake. It is unclear why physical activity might prevent diverticulosis. A clear correlation between constipation and diverticulosis has not been shown, although abnormal colonic motility may predispose to the development of diverticulosis due to increased intraluminal colonic pressures.

Diverticulitis causes a variety of symptoms such as left lower quadrant pain, nausea, vomiting, fevers, even urinary symptoms all the way to walled of perforations, fistulizing disease, colonic obstruction, free perforation and peritonitis. While some patients may only complain of cramping, bloating, flatulence, and irregular defecation, the presentation depends on the severity of inflammation and related complications (abscess, fistula, obstruction, perforation). A physical exam may show abdominal tenderness with or without a tender abdominal mass, abdominal distention, or even severe generalized tenderness suggesting peritonitis due to a perforation. A CT scan is the preferred test in patients suspected of having acute diverticulitis, as it allows for a diagnosis as well as assessment of severity od disease (allowing for identification of major complications i.e. peritonitis, perforation, fistulas, obstruction). Treatment of acute diverticulitis usually requires in- or outpatient antibiotics but may also require CT-guided percutaneous abscesses drainage or even surgery.

Once the acute episode of diverticular disease has resolved, semi-elective follow-up to establish the extent of disease and to rule out coexistent lesions (i.e. carcinoma) is advised. A colonoscopy is likely the test of choice although a CT colography may be an acceptable alternative. Once diverticular disease has resolved, initiation of a high-fiber diet and addition of fiber supplements appear to reduce the risk of subsequent occurrences and complications. Avoidance of small food particles (i.e. nuts/seeds) as often suggested is probably of little proven benefit.

Diverticular bleeding, another complication of diverticulosis is caused by injury to an adjacent arterial vessel and typically occurs in the absence of diverticulitis. Diverticular bleeding is usually painless and often self-limited with intermittent passage of maroon or bright blood. Yet about 5% of patients with diverticulosis may present with significant bleeding; many are over 60 years old and have multiple comorbid conditions. Bleeding is usually managed in the inpatient setting with a colonoscopy being the treatment modality of choice; Interventional Radiology and Surgery may be needed if bleeding can’t be managed with a scope.

And yes: Diverticulosis appears to be hereditary. Patients with diverticular disease often ask whether diverticulosis runs in families. There appears to be good evidence that it does in fact run in families. A recently published study showed a much stronger relative risk in monozygotic compared with dizygotic twins suggesting that there is a real genetic risk. (Strate LL et al. Heritability and familial aggregation of diverticular disease: A population-based study of twins and siblings. Gastroenterology 2013 Apr; 144:736)