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ACP releases new guidelines for screening, management and treatment of diverticulitis

The American College of Physicians (ACP) has released 2 new clinical guidelines on the diagnosis and management of diverticulitis.

The guidelines – which were based on what the organization defined as the best available evidence on clinical benefit and safety, test accuracy, patient prioritization and cost-of-care considerations – address the increasingly common condition of the digestive tract. The recommendations were informed by 2 public members of the CPA’s Clinical Guidelines Committee (CGC) and a 7-member CGC public panel tasked with providing lay input.

Diagnosis and management

The guidelines committee, led by Amir Qaseem, MD, PhD, MHA, provided clinical recommendations on the diagnosis and management of acute left colon diverticulitis in adult patients. It was based on data from a systematic review of the use of computed tomography (CT) for the diagnosis of diverticulitis. Management recommendations were interpreted via hospitalization, use of antibiotics and interventional practices of percutaneous drainage of abscesses.

The ACP made the following 3 recommendations, each conditional and with low-certainty evidence:

  1. Clinicians use abdominal computed tomography when there is diagnostic uncertainty in a patient suspected of having left-sided acute colonic diverticulitis
  2. Clinicians manage most patients with uncomplicated acute left colonic diverticulitis on an outpatient basis
  3. Clinicians initially manage some patients with uncomplicated acute diverticulitis without antibiotics

“A detailed history, physical examination, and laboratory findings are the first steps in the diagnosis of acute bowel diverticulitis in most patients with abdominal pain or tenderness predominantly in the left lower quadrant,” the investigators wrote. “In patients for whom diagnostic uncertainty remains, abdominal CT imaging can be used to supplement history, examination, and laboratory findings to establish the diagnosis of diverticulitis.”

Qaseem and colleagues added that although patients with uncomplicated diverticulitis are “traditionally” managed with antibiotics, emerging concepts in the pathogenesis of the disease suggest an inflammatory versus an infectious cause, calling into question the ‘approach.

“For some patients with acute uncomplicated left-sided colonic diverticulitis presenting with abdominal tenderness, it is reasonable to manage them initially by observation with supportive care (eg, bowel rest and hydration) and without the use of antibiotics “, they wrote.

Diagnostic colonoscopy and recurrence prevention

Qaseem and colleagues again based their recommendations for adults with acute left colon diverticulitis on the results of a systematic review – this time for the role of colonoscopies for disease diagnosis and pharmacological surgical intervention, not pharmacological and elective after the initial treatment.

They again made 3 key recommendations for clinicians:

  1. Clinicians refer patients for colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had a recent colonoscopy (conditional recommendation; low-certainty evidence)
  2. Clinicians do not use mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence)
  3. Clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either persistent or recurrent uncomplicated diverticulitis or complicated diverticulitis (conditional recommendation, low-certainty evidence)

Regarding the third recommendation, the committee added that the decision whether or not to undergo surgery “should be individualized based on a discussion of the potential benefits, harms, costs, and patient preferences.”

They further underscored the importance of preventing recurrence, which occurs in 8-36% of patients between 1 and 10 years after the initial diverticulitis.

“Additionally, patients with complicated diverticulitis may have a higher prevalence of colorectal cancer that presents as acute diverticulitis and is misdiagnosed on clinical examination and/or imaging studies,” they said. writing. “The evidence for the use of various pharmacological, non-pharmacological and surgical interventions to prevent the recurrence of diverticulitis has evolved over time.”

Perspective

In a statement accompanying the new guidelines, CPA President George M. Abraham, MD, MPH, highlighted the growing prevalence of diverticulitis and its risk of long-term, multifactorial impact on patients.

“These clinical guidelines are important topics to better understand how best to approach the best treatment for patients, focusing on outpatient management, with less medication, to help improve a condition that can often lead to quality issues. of life and can lead to more serial conditions if not treated appropriately,” Abraham said. “As always, understanding the benefits, potential harms, and best use is key to counseling patients on treatment options.”

The guidelines have been published online in the Annals of Internal Medicine.