New ACP clinical guidelines address diagnosis, management of adult patients with diverticulitis

ACP recently released two new clinical guidelines on the diagnosis and management of adult patients with diverticulitis.

The first guideline provided clinical recommendations on the diagnosis and management of patients with acute left-sided colonic diverticulitis. It was based on a systematic review on the use of CT for diagnosis and on management with hospitalization, antibiotics, and percutaneous abscess drainage. The second guideline, also based on the current best available evidence about benefits and harms, focused on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated or uncomplicated left-sided colonic diverticulitis. The ACP Clinical Guidelines Committee developed the recommendations, which are applicable to all clinicians and were published Jan. 18 by Annals of Internal Medicine.

In the first guideline, ACP suggested that clinicians:

• use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence),
• initially manage most immunocompetent patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting due to a lack of evidence suggesting a benefit of routine hospitalization for such patients (conditional recommendation; low-certainty evidence), and
• initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence). “Select” patients were defined as immunocompetent patients with uncomplicated left-sided diverticulitis, with no systemic inflammatory response or immunosuppression, who are not medically frail, do not require hospitalization, and can be followed as an outpatient under medical supervision with social and family support.

The evidence was inconclusive to assess benefits and harms for the association between CT imaging and diverticulitis-related patient health outcomes, the comparative effectiveness of antibiotic regimens, and percutaneous drainage versus conservative management for CT-verified abscess, the guideline said.

The second guideline provided the following recommendations:

• ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis if they have not had recent colonoscopy, given that CRC may rarely present with signs and symptoms similar to those of acute complicated diverticulitis and may have similar CT findings (conditional recommendation; low-certainty evidence).
• ACP recommends against clinicians using mesalamine (dose range, 1.2 to 4.8 g/d) to prevent recurrent diverticulitis due to no demonstrated clinical benefits but known harms, such as epigastric pain, nausea, diarrhea, dizziness, rash, and renal and hepatic impairment (strong recommendation; high-certainty evidence).
• ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient preferences.

Evidence was inconclusive about the incremental net benefit of follow-up colonoscopy for detection of CRC after a resolved episode of acute uncomplicated left-sided colonic diverticulitis compared with routine CRC screening. Another area of inconclusive evidence was whether follow-up colonoscopy after acute complicated diverticulitis improves CRC mortality.