Q&A: A deeper dive into ACP's new diverticulitis guidelines
Authors discussed the College's first clinical guidelines on diagnosis and management of diverticulitis, which provide recommendations on when to use imaging, antibiotics, colonoscopy, and other interventions.
Diverticulitis, particularly left-sided diverticulitis, is a common problem internists face in the office and in the hospital. To help improve care for patients with diverticulitis, ACP's Clinical Guidelines Committee released its first two clinical guidelines on the topic this month.
The first guideline provided recommendations on the diagnosis and management of patients with acute left-sided colonic diverticulitis, and the second focused on use of colonoscopy and interventions to prevent recurrence after initial treatment. The guidelines were published Jan. 18 by Annals of Internal Medicine and were summarized in the Jan. 18 ACP Internist Weekly.
“Clinicians and patients face difficult decisions when it comes to evaluation and management of diverticulitis,” said lead author Amir Qaseem, MD, PhD, MHA, FACP, the College's Senior Vice President of Clinical Policy and Chief Science Officer. “ACP's two clinical guidelines are based on the best available evidence on benefits and harms and taking into account the context of costs, patient values, and preferences and hopefully will help in improving the care of our patients.”
ACP Gastroenterology Monthly recently discussed the guidelines with Dr. Qaseem and ACP Clinical Guidelines Committee members Nick Fitterman, MD, MACP, executive director of Huntington Hospital in New York, and Jennifer S. Lin, MD, FACP, director of the Kaiser Permanente Evidence-based Practice Center in Portland, Ore.
Q: What are the most important takeaways from these guidelines for internists?
A: Dr. Fitterman: Antibiotics may be avoided in a very select patient population, [and] imaging is not always needed. The guideline also helps focus physicians on the patients most likely to benefit from subsequent colonoscopy or surgery.
Dr. Lin: For diagnosis, clinicians don't always need to get imaging to confirm the diagnosis of left-sided diverticulitis, but [we] recommend using CT imaging when there is diagnostic uncertainty. For management, most patients with acute diverticulitis can safely be managed as an outpatient, some of whom can be managed initially without the use of antibiotics. For follow-up after acute diverticulitis, patients with complicated left-sided diverticulitis who haven't had a recent colonoscopy should get a colonoscopy after resolution of the acute episode.
Dr. Qaseem: Also, the decision whether or not to undergo surgery in patients with persistent or recurrent or complicated diverticulitis should be personalized based on a discussion of potential benefits, harms, costs, and patients' preferences.
Q: The guideline conditionally recommends initial management of select patients without antibiotics. Which patients does this apply to, and why don't they need antibiotics?
A: Dr. Lin: Increasingly, we as a medical community recognized that diverticulitis has an inflammatory rather than infectious cause, and therefore, how we manage acute uncomplicated diverticulitis has changed over time.
Dr. Fitterman: Immunocompetent patients not requiring hospitalization and without evidence of significant inflammation who are not medically frail, able to tolerate oral intake, and with adequate follow-up capabilities can safely avoid a course of antibiotics and the potential adverse effects associated with antibiotics, including but not limited to the disruption of their microbiome.
Q: When would antibiotics be appropriate to prescribe for a patient with diverticulitis?
A: Dr. Lin: Clinicians should treat with antibiotics when the patient has complicated diverticulitis, has comorbid unstable conditions, is immunosuppressed, or has signs of a systemic inflammatory response. Clinicians may also err on the side of treating with antibiotics initially when symptoms have lasted longer than five days, [the patient] cannot tolerate oral intake (e.g., vomiting), and [if the patient has] other significant comorbidities, even if stable. Also, patients who initially are managed with conservative care who do not improve or who have new or worsening symptoms should be started on antibiotics.
Q: What is the importance of screening for colorectal cancer after diagnosis of diverticulitis?
A: Dr. Fitterman: The evidence reflects that those with complicated left-sided diverticulitis have an association with advanced neoplasia and colon cancer. These patients should get a colonoscopy after the resolution of the acute episode, a minimum of six to eight weeks after the acute episode. While colonoscopy is standard practice after acute complicated diverticulitis, the guideline points out that this is necessary only for those without a recent, adequate colonoscopy and also may not be needed for uncomplicated disease.
Q: What do you hope these guidelines accomplish for the care of patients with diverticulitis?
A: Dr. Fitterman: They will help narrow down who needs antibiotics [and] who needs imaging and follow-up colonoscopy. This will result in more appropriate utilization of resources and improve patient outcomes.