Diverticulitis: time to change "age-old" practices

Cate Swannell
Med J Aust
Published online: 21 July 2019

A NEW review of the diagnosis and management of diverticulitis has recommended changing some “age-old practices”, particularly for those patients with uncomplicated disease according to the authors, published online today by the Medical Journal of Australia.

Diverticular disease is one of the most common gastrointestinal disorders, with significant health burden. The disease is characterised by diverticulosis: the presence of mucosal and submucosal herniations or “pockets” known as diverticula. Up to 50% of people older than 60 years have diverticula, and although largely asymptomatic, around 4% of individuals with diverticula develop diverticulitis throughout their lifetime. It presents as a severe episode of lower abdominal pain that is usually left-sided, accompanied by a low-grade fever, leucocytosis and change in bowel movements. Guidelines classify diverticulitis as complicated or uncomplicated, based on computed tomography (CT) images.

Authors led by Ms Hayley You from the Griffith University School of Medicine and Ms Amy Sweeny, a nurse researcher at Gold Coast Health Emergency, did a systematic search for guidelines on the assessment, diagnosis, classification, imaging, management and prevention of diverticulitis and diverticular disease. The collaborative review team included Dr James Innes, emergency consultant, and Dr Michael Von Papen, colorectal surgeon, at Gold Coast Health.

“The most recent evidence available and international guidelines recommend changing some age-old practices in the diagnosis and management of diverticulitis,” You and colleagues found.

They concluded that:

  • outpatient treatment is now recommended in afebrile, clinically stable patients with uncomplicated diverticulitis;
  • for patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively;
  • for complicated diverticulitis, classified as such due to the presence of abscess, fistula or perforation, non-operative management, including bowel rest and intravenous antibiotics, may be sufficient depending on the size of the abscess. However, patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery;
  • colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria.

“The most significant changes pertain to choosing treatments more wisely for patients with uncomplicated diverticulitis: clinical diagnosis for patients with a history of diverticulitis and mild symptoms, the increased use of outpatient management, use of antibiotics on a selective case-by-case basis, and avoidance of routine colonoscopy unless another clear indication exists,” they concluded.

  • Cate Swannell



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