Key takeaways:
- Follow-up colonoscopy may be recommended to “rule out” underlying malignancy.
- Lifestyle interventions, including diet and exercise, may help reduce recurrence.
ACG has released a clinical guideline for the management of colonic diverticulitis in outpatient settings, highlighting the importance of imaging to rule out other diseases and lifestyle modifications to mitigate recurrence.
Colonic diverticulitis is relatively common and accounts for 1.7 million clinic visits, 452,000 ED visits and an estimated $5.5 billion in health care expenditures annually in the U.S.
At least 25% of individuals diagnosed with diverticulitis will experience recurrence, and that risk increases with subsequent episodes.
“Diverticulitis can be distressing, especially when it recurs,” lead author Anne Peery, MD, MSCR, a gastroenterologist and clinical investigator with expertise in diverticular disease, told Healio. “Gastroenterologists should address diagnostic accuracy, recurrence risk, complications, prevention, antibiotics, surgical consultation and ongoing symptoms.
“Clear patient education is also critical,” she added.
Peery and colleagues created the new guidance and advise its use — along with clinical judgment and consideration of comorbidities, general health and preferences — for patient-centered management of the disease.
‘Rule out’ other diagnoses
At initial presentation and in severe cases, CT imaging is a crucial diagnostic step.
“In patients with a prior confirmed episode, repeat CT may not be necessary if symptoms are typical of prior flares and there are no concerning features such as severe pain, fever, vomiting, chills or an abnormal exam,” Peery said. “Patients who are immunocompromised can develop complications despite mild symptoms, so clinicians should have a low threshold for imaging in that setting.”
The authors noted that colon cancer has been misdiagnosed as diverticulitis in some patients, an error more common among individuals with complicated diverticulitis.
Peery and colleagues recommend colonoscopy to “rule out” colon cancer or premalignant lesions 6 to 8 weeks after a patient recovers from complicated diverticulitis.
They also suggest colonoscopy after an episode of uncomplicated diverticulitis under specific circumstances.
“Follow-up colonoscopy should be considered after uncomplicated diverticulitis in patients with alarm symptoms or who are not up to date with colorectal cancer screening,” Peery said. “Alarm symptoms include unintentional weight loss, changes in bowel habits, iron-deficiency anemia, bloody stools and persistent abdominal pain.”
Hold the antibiotics
Diverging from previous guidance, Peery and colleagues recommend against routine antibiotics for patients with acute uncomplicated diverticulitis and low-risk features.
Four randomized trials showed that antibiotics had no significant impact on mortality, progression to complicated diverticulitis, recurrence, or need for surgery or readmission in this patient population.
“Antibiotics should be reserved for patients with high-risk features, immunocompromise, frailty or when safe outpatient management is not assured,” Peery said. “We included a table to help clinicians identify which patients may be managed without antibiotics and which antibiotic regimens are appropriate when treatment is needed.”
Probiotics, mesalamine and rifaximin also have been evaluated as part of treatment regimens for patients with a history of diverticulitis. However, evidence has not linked these agents to reduced risk for recurrence. Given their cost, potential harms and burden of daily use, the authors recommend against their use.
Lifestyle interventions
Numerous lifestyle interventions have been linked to lower risk for diverticulitis recurrence.
Peery and colleagues highlighted the importance of nutrition and suggest patients with a history of diverticulitis consume a high-fiber diet rich in fruits, vegetables, whole grains and legumes. They also recommend patients limit their intake of red meat, processed grains, trans fats and sweets.
The authors acknowledged the misconception that eating nuts, corn, seeds or popcorn may increase risk for recurrence, but noted evidence does not support avoiding these foods.
Other recommendations included encouraging patients to engage in regular physical activity and maintain a healthy weight.
According to the guideline, clinicians should recommend patients with a history of colonic diverticulitis avoid smoking and only drink alcohol in moderation. Liquor and white wine in particular appear strongly associated with risk for incident diverticulitis.
NSAIDs were another point of concern, as evidence has linked their use to increased risk for incident diverticulitis, which may translate to an increased risk for recurrence.
The authors suggest patients avoid regular use of NSAIDs after recovering from diverticulitis but noted that as evidence on this topic is limited, NSAIDs may be used if clinically indicated.
For patients with recurrent uncomplicated diverticulitis that significantly impact their quality of life, Peery and colleagues recommend referral for a colectomy consultation.
“For patients considering elective surgery, the decision should be based on symptom burden and quality of life, not on preventing emergency surgery,” Peery said.
She emphasized the importance of confirming diverticulitis diagnosis with CT imaging prior to elective surgery, and for individualized conversations about potential risks and benefits of the procedure.
“It’s important for patients to understand the typical course of diverticulitis,” Peery said. “While recurrences can be frustrating and unpredictable, they are generally less likely to lead to complications than the first episode.”
For more information:
Anne Peery, MD, MSCR, is professor of medicine and director of the adult inpatient nutrition support team at The University of North Carolina School of Medicine. She can be reached at anne_peery@med.unc.edu.
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