Does this patient need an antibiotic? Imaging? Physicians discuss diagnosis and treatment strategy for patient with diverticulitis

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0669 

URL goes live when the embargo lifts

In a new Annals ‘Beyond the Guidelines’ feature, two gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease in a patient with diverticulitis. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine. 

Acute diverticulitis is a common medical condition that may occur repeatedly in some patients and generally presents with left-sided abdominal pain that may be accompanied by low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction, which is why proper diagnosis and treatment are important.

In recently published clinical practice guidelines, the American College of Physicians (ACP) recommended the use of abdominal CT scanning in cases where there was diagnostic uncertainty; initial management of uncomplicated cases in the outpatient setting without antibiotics; referral for colonoscopy after an initial episode if not performed recently; and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. However, not every patient falls neatly within guideline parameters.

BIDMC Grand Grounds discussants, Judy W. Nee, MD, Assistant Professor of Medicine at Harvard Medical School, Division of Gastroenterology and Anthony J. Lembo, MD, Director of Research for the Digestive Disease and Surgery Institute at Cleveland Clinic reviewed the case of a 62-year-old woman with recurrent uncomplicated episodes of diverticulitis initially diagnosed by CT scan. In their assessment, both Drs. Nee and Lembo agree with ACP guidelines in that they do not recommend antibiotics for patients diagnosed with mild uncomplicated diverticulitis or advise repeat colonoscopy for patients with uncomplicated diverticulitis who are up to date with routine colorectal cancer screening. Dr. Nee says that a CT scan was important for the initial diagnosis of acute diverticulitis in the patient to rule out alternative causes of abdominal pain and may be warranted now because the patient has recurrent symptoms. However, antibiotics and colonoscopy do not seem necessary because the patient’s diverticulitis is uncomplicated and she is up to date on colonoscopy. Dr. Lembo agrees that colonoscopy is unnecessary, but antibiotics could be warranted unless symptoms are mild. Dr. Nee thinks that the patient should be referred for a discussion about elective surgical resection given her frequent recurrences, as the benefits of this procedure may outweigh the risks. Dr. Lembo would not recommend elective surgery at this time but would advise further discussion with a colorectal surgeon given that the patient expressed a desire for surgery.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. For an interview with the discussants, please contact Kendra McKinnon at [email protected].