ACP Releases New Guidelines for Screening, Management and Treatment of Diverticulitis

The American College of Physicians (ACP) has published two new clinical guidelines for diagnosis and treatment Divertikulitis.

The guidelines—which were based on what the organization defined as the best available evidence on clinical utility and safety, testing accuracy, patient prioritization, and cost-of-care considerations—address the emerging disorders of the digestive tract. The recommendations were made by 2 public members of the ACP Clinical Guidelines Committee (CGC) and a 7-member CGC public panel tasked with providing lay input.

diagnosis and management

The guidelines committee, headed by Amir Qaseem, MD, PhD, MHA, provided clinical recommendations for the diagnosis and management of acute left-sided colonic diverticulitis in adult patients. It was based on data from a systematic review of the use of computed tomography (CT) to diagnose diverticulitis. Treatment recommendations were interpreted based on hospitalization, use of antibiotics, and interventional percutaneous abscess drainage practices.

The ACP made the following 3 recommendations, each with conditions and low-certainty evidence:

  1. Physicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis
  2. Clinicians treat most patients with acute uncomplicated left-sided colonic diverticulitis on an outpatient basis
  3. Doctors initially treat selected patients with acute uncomplicated diverticulitis without antibiotics

“A detailed history, physical examination, and laboratory findings are the first steps in diagnosing acute colonic diverticulitis in most patients with abdominal pain or tenderness primarily in the left lower quadrant,” the researchers wrote. “In patients in whom there is diagnostic uncertainty, abdominal CT imaging can be used to supplement history, examination, and laboratory findings to help establish a diagnosis of diverticulitis.”

Qaseem and colleagues added that although patients with uncomplicated diverticulitis are “traditionally” treated with antibiotics, emerging concepts in the pathogenesis of the disease point to an inflammatory or infectious cause, calling the approach into question.

“In select patients with acute, uncomplicated left-sided colonic diverticulitis manifested by abdominal tenderness, it is reasonable to initially treat them by observation with supportive care (e.g., bowel rest and hydration) and without the use of antibiotics,” they wrote .

Diagnostic colonoscopy and recurrence prevention

Qaseem and colleagues again based the recommendations for adults with acute left-sided colonic diverticulitis on the results of a systematic review – this time on the role of colonoscopy in the diagnosis of disease and pharmacological, non-pharmacological and elective surgical interventions after initial treatment.

They again made 3 key recommendations for clinicians:

  1. Clinicians refer patients for colonoscopy after a first episode of complicated left-sided colonic diverticulitis in patients who have not had a recent colonoscopy (conditional recommendation; low-certainty evidence)
  2. Clinicians do not use mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence)
  3. Clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients with either uncomplicated diverticulitis that persists or frequently recurs or complicated diverticulitis (conditional recommendation, low-certainty evidence)

Regarding the third recommendation, the committee added that the decision to undergo surgery or not “should be personalized based on a discussion of potential benefits, harms, costs, and patient preferences.”

They also emphasized the importance of preventing a recurrence, which occurs in 8% to 36% of patients between 1 and 10 years after initial diverticulitis.

“In addition, patients with complicated diverticulitis may have a higher prevalence of colorectal cancer presenting as acute diverticulitis and misdiagnosed on clinical examination and/or imaging studies,” they wrote. “The evidence supporting the use of various pharmacological, non-pharmacological, and surgical interventions to prevent recurrence of diverticulitis has evolved over time.”

perspective

In a statement accompanying the new guidelines, ACP President George M. Abraham, MD, MPH, emphasized the increasing prevalence of diverticulitis and its risk of multifactorial, long-term effects on patients.

“These clinical guidelines are important topics to better understand how best to approach the best course of treatment for patients, which focuses on management in an outpatient setting with fewer medications to help improve a condition that often results in limitations of the patient quality of life can and can lead to more serial conditions if not treated appropriately,” Abraham said. “As always, understanding the benefits, potential harms, and best practice is critical when advising patients on treatment options.”

The guidelines were published online in the Annals of Internal Medicine.

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Reference-www.nach-welt.com

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