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Awaiting acute diverticulitis dx & severity assessment
Don’t make dx based on clinical presentation alone;1,2 poor correlation exists btwn clinical findings & dz severity;2,3 labs & imaging important for accurate dx, discovery of complications, & planning of tx1-4 - Begin eval w/ H&P,1,4,5 but don’t rely on clinical presentation alone:1-3 classic findings include fever, LLQ pain;4 fecaluria, pneumaturia, stool per vagina may indicate associated fistula4
- Labs helpful in initial eval: ↑WBC is part of classic findings, but nonspecific;1,2,4 pyuria on UA may indicate colo-vesical fistula;4 ↑CRP or procalcitonin may be predictive of complicated diverticulitis4 (ESCP disagrees);3 ↑fecal calprotectin may predict recurrence risk1,4
- Perform imaging to confirm dx1-5 (esp if not prev done, per ESCP, AGA, or if dx uncertain, per ACP): CT is preferred 1st-line imaging,1-4 contrast preferred by WSES, AGA but not req’d, per ASCRS (95% sens/spec w/o contrast);4 US is an alternative, can be used 1st line if expert technician, per WSES,1 but may miss complications;3,4 "step up" to CT if US(-) or inconclusive may be a safe option;1 MRI also an option in pts who can’t do CT2-4
- Determine if dz is complicated w/ presence of any of these on imaging: fluid outside of colon, air/gas beyond colonic lumen; abscess,1,3-4 stricture, obstruction, fistula4
- Consider observation w/o imaging if mild, recurrent dz w/ low CRP3
Footnotes 1 WSES 2020. Sartelli M, et al. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting. World Society of Emergency Surgery. World J Emerg Surg. 2020. May 7;15(1):32. PubMed® abstract | Free full-text PDF @ PubMed® Central
2 AGA 2021. Peery AF, et al. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021. Feb;160(3):906–911. Free full-text PDF
Clinical suspicion of diverticulitis alone is correct in only 40%–65% of pts. CT abd/pelvis w/ PO & IV contrast is 95% sensitive/specific for dx of acute diverticulitis.
Also consider CT to eval for potential complications in pts w/ severe presentations, those who fail to improve w/ tx, are immunocompromised, or who have multiple recurrences and are contemplating prophylactic surgery.
3 ESCP 2020. Schultz JK, et al. European Society of Coloproctology: Guidelines for the Management of Diverticular Disease of the Colon. European Society of Coloproctology. Colorectal Dis. 2020. July 7. doi:10.1111/codi.15140. Online ahead of print. PubMed® abstract | Free full-text article
4 ASCRS 2020. Hall J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2020. June;63(6):728-747. PubMed® abstract | Free full-text PDF
Micro-perforation w/ small amounts of contained, extraluminal gas, in the absence of a systemic inflammatory response is not considered complicated dz.
5 ACP 2022. Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. (Epub ahead of print 18 January 2022) doi:10.7326/M21-2710. Free full-text article
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Unstable pt w/ complicated dz Reserve surgical intervention for critically ill, those failing medical tx; laparoscopic lavage is controversial, not 1st line for diffuse peritonitis - Initiate abx for all1-4
- Perform resection as tx of choice if overt perforation/feculent peritonitis:2,3 Use minimally invasive approach, if expertise available2-4
- Use Hartmann’s procedure in critically ill pts & in select pts w/ multiple comorbidities;3-4 per ASCRS, decision to restore bowel continuity should incorporate pt factors, intraoperative factors, & surgeon pref2
- Consider staged, damage control strategy (DCS) in selected unstable pts w/ perforation & diffuse peritonitis4
- Consider laparoscopic lavage only in very select pts w/ diffuse peritonitis;3,4 rec'd against in pts w/ feculent peritonitis;2 reasonable, per ESCP;3 but inferior to colectomy in purulent peritonitis (↑need for 2nd procedure), per ASCRS2
Footnotes 1 AGA 2015. Stollman N, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. American Gastroenterological Association. Gastroenterology. 2015. Dec;149(7):1944-9. PubMed® abstract | Free full-text PDF
2 ASCRS 2020. Hall J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2020. June;63(6):728-747. PubMed® abstract | Free full-text PDF
3 ESCP 2020. Schultz JK, et al. European Society of Coloproctology: Guidelines for the Management of Diverticular Disease of the Colon. European Society of Coloproctology. Colorectal Dis. 2020. July 7. doi:10.1111/codi.15140. Online ahead of print. PubMed® abstract | Free full-text article
4 WSES 2020. Sartelli M, et al. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting. World Society of Emergency Surgery. World J Emerg Surg. 2020. May 7;15(1):32. PubMed® abstract | Free full-text PDF @ PubMed® Central
DCS: Initial surgery focuses on control of the sepsis, & subsequent operation deals w/ anatomical restoration of GI tract, after a period of physiological resuscitation. This strategy facilitates both control of the severe sepsis, as well as potentially improving the rate of primary anastomosis.
Multiple comorbidities, a high CRP level, and/or a high Mannheim Peritonitis Index were also predictors of a high risk of failure of laparoscopic lavage.
Stable pt w/ complicated dz Abx indicated for all complicated dz; monitor for failure of non-operative tx, esp in immunocompromised pts; refer for surgical intervention as last resort - Initiate abx for all1-5
- Monitor immunocompromised pts: high risk of failure of medical tx4,5
- Consider percutaneous drainage if abscess >3cm2,3 (>4-5cm, per WSES),4 due to high abx failure rate; consider trial of abx alone vs surgical intervention, if percutaneous drainage not clinically possible.4 Surgery is last resort for pt w/ abscess failing non-surg tx3
- Refer pt for surgical intervention if: develops s/sx of sepsis or systemic inflammatory response,2,3 other hemodynamic instability;3 or fails/worsens w/ non-operative tx2
- In stable pts w/o comorbidities who require surgery: Consider primary resection with anastomosis +/- diverting stoma;3,4 per ASCRS, decision to restore bowel continuity should incorporate pt factors, intraoperative factors, and surgeon pref2
- Consider laparoscopic lavage only in very select pts w/ diffuse peritonitis;3,4 rec’d against in pts w/ feculent peritonitis;2 reasonable, per ESCP;3 but inferior to colectomy in purulent peritonitis (↑ need for 2nd procedure), per ASCRS2
- Don’t limit diet or activity: unrestricted diet pref’d, bed rest not rec’d due to potential to ↓general condition3
Footnotes 1 AGA 2015. Stollman N, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. American Gastroenterological Association. Gastroenterology. 2015. Dec;149(7):1944-9. PubMed® abstract | Free full-text PDF
2 ASCRS 2020. Hall J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2020. June;63(6):728-747. PubMed® abstract | Free full-text PDF
3 ESCP 2020. Schultz JK, et al. European Society of Coloproctology: Guidelines for the Management of Diverticular Disease of the Colon. European Society of Coloproctology. Colorectal Dis. 2020. July 7. doi:10.1111/codi.15140. Online ahead of print. PubMed® abstract | Free full-text article
There is little evidence to determine whether or not pericolic or free air alone is an indication for surgery.
4 WSES 2020. Sartelli M, et al. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting. World Society of Emergency Surgery. World J Emerg Surg. 2020. May 7;15(1):32. PubMed® abstract | Free full-text PDF @ PubMed® Central
5 AGA 2021. Peery AF, et al. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021. Feb;160(3):906–911. Free full-text PDF
Uncomplicated dz likely inflammatory, not infectious & may be self-limited;1 reserve abx for select pts - May tx uncomplicated dz as outpt2,3 if all are true: tolerating PO, adequate social network, immunocompetent, no sepsis or hemodynamic instability, no significant comorbidity;2,4 re-eval in 7 days, per WSES (sooner if deteriorating)2
- Admit for inpt medical tx if any are true: uncomplicated dz on imaging, but pt w/ significant comorbidity or unable to tolerate PO fluids; immunocompromised pt (esp due to steroids); deterioration w/ outpt tx2
- Reserve abx for: immunocompromised pts & those w/ significant comorbidity;1,3,5,6 per AGA, also start abx for pts who: are frail; present w/ refractory sx or vomiting; have CRP >140 mg/L or baseline WBC >15x109 cells/L; have a fluid collection or longer segment of inflammation on CT scan6
- Consider shorter courses of abx, when req’d, 4-day course as effective as 7 days;5 switch to PO as soon as possible2
- Monitor immunocompromised pts: high risk of failure of medical tx2,6
- Refer pt for surgical intervention if: develops s/sx of sepsis or systemic inflammatory response,4,5 other hemodynamic instability;4 or fails/worsens w/ non-operative tx5
- Don’t limit diet or activity: Unrestricted diet preferred by ESCP,4 although AGA advises clear liquid diet for pt comfort;6 bed rest not rec’d due to potential to ↓general condition4
Footnotes 1 AGA 2015. Stollman N, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. American Gastroenterological Association. Gastroenterology. 2015. Dec;149(7):1944-9. PubMed® abstract | Free full-text PDF
2 WSES 2020. Sartelli M, et al. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting. World Society of Emergency Surgery. World J Emerg Surg. 2020. May 7;15(1):32. PubMed® abstract | Free full-text PDF @ PubMed® Central
3 ACP 2022. Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. (Epub ahead of print 18 January 2022) doi:10.7326/M21-2710. Free full-text article
4 ESCP 2020. Schultz JK, et al. European Society of Coloproctology: Guidelines for the Management of Diverticular Disease of the Colon. European Society of Coloproctology. Colorectal Dis. 2020. July 7. doi:10.1111/codi.15140. Online ahead of print. PubMed® abstract | Free full-text article
5 ASCRS 2020. Hall J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2020. June;63(6):728-747. PubMed® abstract | Free full-text PDF
6 AGA 2021. Peery AF, et al. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021. Feb;160(3):906–911. Free full-text PDF
Longer segment of inflammation on baseline CT (86 mm vs 65 mm) is associated w/ ↑ risk of progression to complicated diverticulitis.
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Recovered from acute episode
Consider increased risk of occult CA in pts w/ h/o complicated dz; diet & lifestyle changes warranted to prevent recurrence; elective resection not routine, reserve for select pts based on presence of certain complications, severity of dz, comorbidity, etc - Advise diet/lifestyle changes to prevent recurrence: wt loss,1,2 smoking cessation,1,2 vigorous physical activity,1-3 ↓meat intake;1 high-fiber diet suggested by AGA,2,3 but little evidence, per ESCP;4 don’t advise against dietary seeds/nuts/popcorn/strawberries2,3
- Suggest avoiding non-aspirin NSAIDs, when possible; don’t advise against aspirin for secondary ASCVD prevention2,3
- R/O occult malignancy w/ colonoscopy after recovery from medically-treated complicated dz (esp abscess, per WSES),5 if not recently done;1-3,5 timing: after 6-8wk, per AGA;2 after 4-6wk, per WSES;5 after 6wk, per ESC.4 Pts w/ uncomplicated dz do not need f/u colonoscopy unless atypical recovery, per ASCRS,1 although ACP & AGA advise colonoscopy after 1st episode if not previously done2,6
- If pt w/ persistent, chronic symptoms, ongoing inflammation should be excluded w/ both imaging and lower endoscopy; if no evidence of diverticulitis, visceral hypersensitivity should be considered and managed accordingly2
- Evaluate pt-related factors,5,6 not # of recurrences, when considering elective colectomy;2,4,5 consider complications (eg, abscess, fistula, stricture),1 severity of episodes, pt’s circumstances/comorbidities;2,3,5 per ASCRS & ESCP, immunocompromise or young age shouldn’t drive decision to resect after uncomplicated dz1,4 (however, WSES suggests elective resection in immunocompromised)5
- Don’t routinely recommend probiotics, mesalamine,6 or rifaximin to prevent recurrence1-4
Footnotes 1 ASCRS 2020. Hall J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2020. June;63(6):728-747. PubMed® abstract | Free full-text PDF
2 AGA 2021. Peery AF, et al. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021. Feb;160(3):906–911. Free full-text PDF
3 AGA 2015. Stollman N, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. American Gastroenterological Association. Gastroenterology. 2015. Dec;149(7):1944-9. PubMed® abstract | Free full-text PDF
4 ESCP 2020. Schultz JK, et al. European Society of Coloproctology: Guidelines for the Management of Diverticular Disease of the Colon. European Society of Coloproctology. Colorectal Dis. 2020. July 7. doi:10.1111/codi.15140. Online ahead of print. PubMed® abstract | Free full-text article
5 WSES 2020. Sartelli M, et al. 2020 Update of the WSES Guidelines for the Management of Acute Colonic Diverticulitis in the Emergency Setting. World Society of Emergency Surgery. World J Emerg Surg. 2020. May 7;15(1):32. PubMed® abstract | Free full-text PDF @ PubMed® Central
Pt-related factors assoc w/ recurrence: female gender, young age, smoking, obesity, complicated initial dz.
6 ACP 2022. Qaseem A, et al. Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. (Epub ahead of print 18 January 2022) doi:10.7326/M21-2711. Free full-text article
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