News

Calls to change ‘age-old’ diverticulitis practices


Matt Woodley


29/07/2019 3:30:50 PM

A review of current guidelines for one of Australia’s most common gut disorders has found treatments should be chosen more wisely.

Diverticulitis is a common gut disorder.
Diverticulitis presents as a severe episode of lower abdominal pain that is usually left-sided.

In particular, the Griffith University study recommends updating practices used to treat patients with uncomplicated diverticulitis and mild symptoms.
 
Dr James Innes, an emergency consultant who contributed to the review into the diagnosis and management of the disease, told newsGP the updated recommendations apply to GPs and emergency doctors alike.
 
‘For patients with a history of diverticulitis, and mild symptoms suggestive of recurrence, diagnosis does not need to be confirmed by CT scan,’ Dr Innes said.
 
‘Outpatient management can proceed, including; a couple of days of clear fluid diet followed by a low fibre diet until pain resolves; pain management with acetaminophen and antispasmodics; and instructions to return if symptoms worsen or do not improve after a few days.
 
‘Furthermore, routine colonoscopy six weeks post complicated diverticulitis is still warranted, but it is not necessary for uncomplicated diverticulitis cases, unless the patient meets other criteria as per the national bowel screening program.’
 
The review also found antibiotics provide no assistance for uncomplicated cases of diverticulitis and recommends their selective use on a case-by-case basis.
 
‘GPs should definitely be aware that antibiotics have not been shown to shorten recovery time or reduce pain from uncomplicated diverticulitis,’ Dr Innes said.
 
‘This is because diverticulitis is a condition of inflammation, but not always infection. Inflammation does not require antibiotics – just time and rest.
 
‘So, patients that require antibiotics for other purposes, or immunosuppressed patients, may still benefit from antibiotics if they have a bout of uncomplicated diverticulitis, but, for most, the risks would outweigh the benefits.’
 
One of the most common gastrointestinal disorders, diverticular disease is characterised by diverticulosis – the presence of mucosal and submucosal herniations or ‘pockets’ known as diverticula. Although largely asymptomatic, up to 50% of people 60 years and older have diverticula, around 4% of whom develop diverticulitis throughout their lifetime.
 
It presents as a severe episode of lower abdominal pain that is usually left-sided, accompanied by a low-grade fever, leucocytosis and change in bowel movements. Guidelines classify diverticulitis as complicated or uncomplicated, based on computed tomography (CT) images.



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Philip Kemp   30/07/2019 7:53:05 AM

Nice update - however if you are going to refer to 'new' guidelines, either include them in the article or provide a link to them.


Dr Dilip Singh Chauhan   30/07/2019 8:28:02 AM

I n my experience of47 years I have found combination of colofac and flagyl and switching to drink hot water after meal
has given good results


Dr Jitendra Natverlal Parikh   30/07/2019 10:56:59 AM

It is interesting that paracetamol as analgesic is not mentioned


Dr Jitendra Natverlal Parikh   30/07/2019 10:59:36 AM

How silly of me to comment without finding what is acetoaminophen


Dr Gobind Singh Duggal   30/07/2019 4:41:56 PM

I find giving Flagyl hastens the resolution of symptoms faster, I think there is associated infection with acute symptoms in most cases


A.Prof Christopher David Hogan   30/07/2019 7:46:20 PM

There is a Universal Medical Answer- It Varies.
Diverticulae have many causes, not just the effect of chronic constipation from a low fibre diet. There are syndromes of connective tissue which have one or more of diverticulae, inguinal hernias, aortic aneurysms, recurrent dislocations and polycystic disease of kidneys & liver.
It is always wise to look just a little beyond the obvious to ensure nothing else is going on. Assumptions are dangerous


newsGP   2/08/2019 12:57:40 PM

Thanks for your comment, Philip Kemp. The article refers to a review of the existing guidelines and a link is provided to this review in the first paragraph. There are no new guidelines mentioned anywhere in the article.


Paul Griffiths   3/08/2019 6:35:23 AM

I agree with the limited role of metronidazole or augmentin. What I have issue with is the contradiction of saying limited role in uncomplicated diverticulitis, mild symptoms on previous diverticulitis doesn’t require a CT scan but then the definition of whether it is complicated or uncomplicated is based on CT scan. It is going to misdiagnose and missmanage the group with prior uncomplicated diverticulitis who have subsequent early complicated diverticulitis. Diverticulitis trends towards complex with recurrence.


Dr No   3/08/2019 6:46:34 AM

A bit disappointing to see the doctors who think “in my experience” is more valuable than the evidence.


Adrian Elliot-Smith   3/08/2019 8:29:16 AM

I think these three quotes need a bit more fleshing out
……..

‘For patients with a history of diverticulitis, and mild symptoms suggestive of recurrence, diagnosis does not need to be confirmed by CT scan,’

‘GPs should definitely be aware that antibiotics have not been shown to shorten recovery time or reduce pain from uncomplicated diverticulitis,’

“Guidelines classify diverticulitis as complicated or uncomplicated, based on computed tomography (CT) images.”

……..

So you don’t need the CT for diagnosis but you do to determine if it is uncomplicated (and therefore not requiring antibiotics) - or am I misinterpreting the logic!


Horst Herb   3/08/2019 12:07:14 PM

I quote: """‘Outpatient management can proceed, including; a couple of days of clear fluid diet followed by a low fibre diet until pain resolves; """

Is this a typo? While the benefits of a high fibre diet is still debated in the context of acute diverticulitis, I have yet to find any evidence that would recommend a low fibre diet. It would fly in the face of everything we believe we know about diverticulitis!

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866096/


Dr Trevor Evans   3/08/2019 4:53:10 PM

Once symptoms have settled I have for decades advised patients to get back to a high fibre diet. Then at the return of the symptoms to go to a low residue diet again. And so on. No mention was made of hi fibre diet when asymptomatic.
Is this advice no longer valid?


Dr. Mark Karaczun   16/08/2019 6:17:50 AM

A wise pathologist told me that the cause of diverticula was 'poor design [of the intestinal tissues] by God'. The squat versus sit hypothesis makes sense to me. (see link)
RE: fibre, my understanding was that soluble fibre was beneficial, but insoluble fibre could worsen the condition. I found this article , albeit from a few years ago, very helpful: https://www.todaysdietitian.com/newarchives/030314p46.shtml The differentiation between diarrhoea-dominant and constipation-dominant diverticular disease is not something I ever considered.
RE: 'evidence' there is much to be gained from both inductive and deductive approaches. Publication bias and conflicts of interest raise the caveat of 'evidence-biased medicine' to which we should not be slavish, IMHO.


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