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January 18, 2022
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ACP releases inaugural guidelines for acute left-sided colonic diverticulitis

Disclosures: Healio Primary Care could not confirm relevant financial disclosures at the time of publication.
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The ACP has released its first-ever guidelines for diagnosing, managing and preventing recurrence of acute left-sided colonic diverticulitis.

An estimated 5% to 10% of patients with diverticulosis may develop acute diverticulitis, with the risk increasing with age, according to the guideline authors. The incidence of acute diverticulitis appears to be rising, with right-sided colonic diverticulitis more prevalent in Asian countries and left-sided colonic diverticulitis more prevalent in Western countries.

An infographic that reads according to the ACP, acute left-sided colonic diverticulitis causes about 200,000 hospitalizations annually in the United States.
Reference: ACP

In the U.S., there are about 200,000 hospitalizations due to acute left-sided colonic diverticulitis each year, the guideline authors wrote. The cost of annual hospitalizations linked to a principal diagnosis of acute diverticulitis have topped $8 billion in the U.S. in recent years.

Diagnosis and management

For the diagnosis and management of acute left-sided colonic diverticulitis, the ACP recommends:

  • using abdominal CT scans to diagnose the condition in instances of diagnostic uncertainty;
  • managing most patients in an outpatient setting; and
  • initially managing “select” patients with supportive care without antibiotics.

The guideline authors said that “select” patients could be defined as those with acute left-sided colonic diverticulitis who are immunocompetent and have no evidence of systemic inflammatory response or immunosuppression, who are not medically frail, do not need hospitalization, and can follow up as an outpatient under medical supervision and societal and familial support.

George Abraham

George Abraham, MD, MPH, MACP, FIDSA, the president of ACP and a practicing internist, said in a video accompanying the guidelines’ release that “although the traditional management includes antibiotics, ACP’s review of the literature found that evidence did not support their use for uncomplicated diverticulitis and suggest treatment without the use of antibiotics.”

Preventing recurrence

About 8% to 36% of patients with acute left-sided colonic diverticulitis will experience recurrence at 1 to 10 years, according to the guideline authors. To help prevent recurrence, the ACP recommends referring patients for a colonoscopy after an episode of complicated left-sided colonic diverticulitis if they had not recently received one.

“ACP suggests that clinicians refer patients who have not had recent colonoscopy to get one so that colorectal cancer, while rare, can be ruled out for their symptoms,” Abraham said.

The ACP also recommends that clinicians:

  • avoid the use of mesalamine to prevent recurrence; and
  • talk to patients about the potential benefits, harms, costs and their preferences about utilizing elective surgery to prevent recurrent diverticulitis if it is “persistent or recurs frequently or complicated.”

Conversations about elective surgery should be a shared decision-making process with the patient, primary care physician, gastroenterologist and surgeon, Abraham said.

Of all the recommendations for diagnosing, managing and preventing recurrence of acute left-sided colonic diverticulitis, the only strong recommendation based on high-certainty evidence is the one that discourages prescribing mesalamine.

“Evidence reviewed showed mesalamine resulted in no difference in the risk of recurrent diverticulitis compared to placebo and may not improve symptoms,” Abraham said.

The inaugural guidelines, which were published in Annals of Internal Medicine, are based on a review of 78 papers, most of them with a moderate or high risk for bias. The cohorts in these articles tended to be in their 40s or older, and the percentage of men, when reported, ranged from 28% to 64%.

References:
Qaseem A, et al. Ann Intern Med. 2022;doi:10.7326/M21-2710.
Qaseem A, et al. Ann Intern Med. 2022;doi:10.7326/M21-2711.