Reflecting research-driven changes in clinical practice, a revised set of evidence-based recommendations for the medical and surgical treatment of left-sided colonic diverticulitis has been published in Diseases of the Colon & Rectum (DC&R), the official journal of the American Society of Colon and Rectal Surgeons (ASCRS). The journal is published by Wolters Kluwer.
Developed by a panel of the ASCRS Clinical Practice Guidelines Committee, the new recommendations were posted today on the DC&R website and will appear in the journal’s June issue. “As our understanding of diverticulitis has evolved, so have recommendations for the clinical management of these patients,” according to the guideline statement. The lead author is Jason Hall, MD, MPH, of Boston University School of Medicine.
Shift Toward Outpatient Care, Non-Emergency Surgery for Diverticulitis
Colonic diverticulitis is a very common gastrointestinal disorder, accounting for hundreds of thousands of hospitalizations and emergency department visits each year – with costs of $1.6 billion or more. Diverticulitis occurs when small sacs or pouches in the colon wall (diverticula) become inflamed, causing symptoms such as abdominal pain or tenderness and fever. Some patients develop systemic infections or other serious complications, requiring surgical treatment.
Although diverticulitis can occur anywhere in the colon (large intestine), the clinical practice guideline focuses on left-sided diverticulitis as this is the most common site of presentation. Recommendations reflect the “changing treatment paradigm” for diverticulitis: more patients being treated as outpatients and fewer undergoing emergency surgery, while more patients are undergoing elective or laparoscopic (minimally invasive) surgery. Key points include:
- Recommendations for Initial evaluation of acute diverticulitis, emphasizing key physical examination findings and the results of computed tomography (CT) scanning of the abdomen and pelvis.
- Approaches to medical management, including recent evidence that not all patients with acute diverticulitis need antibiotics. Higher-risk patients should receive antibiotics, while some patients with mild disease may not benefit from antibiotics.
- Some patients with diverticulitis will develop associated abscesses and may benefit from antibiotics alone or a procedure to drain the infection.
- Lifestyle changes to potentially reduce the risk of diverticulitis: tobacco cessation, reduced meat intake, physical activity, and weight loss.
- Evaluation after recovery from complicated diverticulitis, including colonoscopy to confirm the diagnosis and exclude the possibility of colon cancer.
- Guidelines for elective surgery: recommended for patients with complications such as fistula, obstruction, or strictures. For patients with recurrent episodes, elective surgery may improve quality of life.
- Guidelines for emergency surgery: still required in 15 to 32 percent of patients hospitalized for diverticulitis. The guideline addresses factors to consider in deciding whether to create a stoma or restore bowel continuity in patients undergoing emergency surgery.
Other recommendations address technical considerations related to surgical treatment of left-sided diverticular disease. “When expertise is available, a minimal approach to colectomy [colon surgery] for diverticulitis is preferred,” the Guideline Committee writes.
DOI: 10.1097/DCR.0000000000001679
