Diverticular Disease

Educational Objectives

The goal of this program is to improve management of diverticular diseases. After hearing and assimilating this program, the clinician will be better able to:

1. Manage diverticular disease and its associated complications.
2. Counsel patients on ways to reduce risk for recurrence of diverticulitis.

Summary

Diverticulitis: diverticuli are small, sac-like, thin-walled, weak protrusions that occur where the vasa recta penetrate in the mucosal walls of the colon; herniation of all the layers of the colon may occur, causing bleeding or infection because of bacterial stasis or fecal impaction; translocation of bacteria through the diverticuli can occur and lead to microabscesses, inflammation, and inflammatory response; incidence of acute diverticulitis increases with age; ≈60% of people ≥60 yr of age have some element of diverticulosis on imaging or colonoscopy; of these, <5% develop diverticulitis; the incidence of diverticulitis is increasing overall and is increasing most rapidly in adults 30 to 50 yr of age; this increase is attributed to use of computed tomography (CT) for most people who present to the emergency department with left lower quadrant pain and increase in risk factors (eg, obesity, dietary changes)

Investigation: in general, suspicion of the first episode of diverticulitis warrants CT because clinical suspicion alone is accurate in only 40% to 60% of cases; CT has sensitivity and specificity of 95%; according to guidelines, imaging is indicated if the patient has not had prior imaging, presentation that lasts >5 days, signs and symptoms of complicated diverticular disease (eg, perforation, obstruction, abscess), immunocompromised status, or an uncertain case

Clinical presentation: diverticulitis is painful but often improves; ≈12% of patients with diverticulitis develop a complication, including abscesses (most common), peritonitis, perforation, obstruction, stricture, and eventually fistula formation

Management: surgical trials demonstrated that antibiotics do not hasten recovery or reduce complications in the setting of acute diverticulitis; AVOD trial (Isacson et al [2019]) found no difference in abscess formation, rate of recurrence, or time to recovery between antibiotics and watchful waiting in patients with CT-confirmed diverticulitis; Daniels et al (2017) found no difference in pain score, recovery rate, or long-term outcomes (eg, recurrence, complications) between amoxicillin plus clavulanic acid (Augmentin) and no antibiotics in patients with CT-confirmed diverticulitis

Medical management: typical regimens are amoxicillin plus clavulanic acid or metronidazole plus a fluoroquinolone; the risk for hospital admission and surgery at 1 and 3 yr are similar between regimens, but the risk for Clostridioides difficle is higher with fluoroquinolones; the aim is gram-negative rods and anaerobic coverage; for patients who have no abscess or other complications, oral antibiotics for 4 to 7 days in an outpatient setting is sufficient; for high-risk patients (eg, after transplantation or with immunocompromised or immunosuppressed status, elevated white blood cell count, elevated C-reactive protein, long segment of inflammation on CT, or sepsis), antibiotics are required; individuals with comorbidities, history of smoldering or refractory diverticulitis, or low likelihood of follow-up may also benefit from antibiotics; for low-risk patients, CT is appropriate if it is the first episode or if their presentation is different than prior episodes; decide appropriately if antibiotics are needed; most outpatients do not need antibiotics

Dietary restrictions: speaker advises a clear liquid diet, and then slowly advance; for pain, offer antispasmodics, acetaminophen, hyoscyamine, and dicyclomine instead of opiates

Colonoscopy: as per guidelines, colonoscopy is advised in the next 6 to 8 wk after initial diagnosis; it demonstrates previously unknown colon cancer in ≈2% of patients with uncomplicated disease and ≈8% of those with complicated diverticulitis; patients with diverticular disease have torturous colons, and small cancers can be easily missed

Recurrence: recurrent diverticulitis is common; risk for recurrence is 8% at 1 yr after the first episode and increases with subsequent episodes; although the risk for recurrence is high, the risk for complications is low; 12% of patients with acute diverticulitis present with complicated diverticulitis, but with an uncomplicated diverticulous attack, the risk for complicated diverticular disease is <5% in recurrent episodes; the risk for recurrence drastically increases if the patient has diverticulitis with abscess on the first episode; 80% of complications occur during the index attack

Surgery: reduces but does not eliminate risk for recurrence; risk for recurrence with surgery is lower (6% at 1 yr) compared with medical management; at 5 yr, the risk for recurrence with surgery is 15%; risks include adhesions, immediate postoperative complications, risks related to anesthesia, and death; risk of needing a permanent ostomy is higher with diverticular disease than with other abdominal surgeries

Reducing the risk for recurrence: patients with higher body mass index have higher risk for diverticulitis and recurrence; consistent physical exercise decreases the risk; nonsteroidal anti-inflammatory drugs increases it; a diet high in dietary fiber, not necessarily supplementary fiber, reduces risk for recurrence; data also show that a diet low in red meat and sweets decreases the risk; nuts, popcorn, corn, and small seeds from fruits and breads do not increase risk; nonmodifiable risk factors include family history and genetic factors; ≈50% of the risk for diverticulitis and recurrence is genetic; Liu et al (2017) reported that adhering to low-risk factors and behaviors reduces risk by ≤75%; ≈50% of the population-attributable risk is related to diet and behavioral modifiers

Indications for surgery: include smoldering diverticulitis (diverticulitis that does not improve), frequent or severe attacks (especially with complications), severe effect on quality of life, recurrent episodes, immunocompromised patients, patient preference, and consistent attacks in the same location, usually in the sigmoid colon; colorectal surgery is not recommended for <3 episodes or for relatively mild cases that improve with antibiotics or watchful waiting; often, a form of irritable bowel syndrome can resemble diverticulitis but has normal imaging findings; this does not require surgery; surgery is not recommended for diverticulitis at multiple locations in the colon or for poor surgical candidates

Smoldering diverticulitis: describes refractory diverticulitis that recurs after discontinuation of therapy or does not improve with antibiotics; this can occur in patients with multiple prior recurrences; these patients are more likely to require surgery; 50% of individuals have an abscess that was undetected at the time of surgery, and 90% improve after surgery; one can consider admission for intravenous antibiotics

Symptomatic uncomplicated diverticular disease (SUDD): the speaker believes that it is similar to postinfectious irritable bowel syndrome, but of the colon caused by diverticulitis; after an episode of diverticulitis, a patient is at higher risk of developing SUDD compared with diverticular disease without an infection

Segmental colitis associated with diverticulitis (SCAD): is similar to inflammatory bowel disease (IBD) but is continuous in distribution; patients with SCAD are typically older than patients with IBD; SCAD always spares the rectum (unlike ulcerative colitis) and has a lower relapse rate; use oral mesalamine to start; if it does not improve, it can become refractory and require surgery

Readings

Alcantar DC, Rodriguez C, Fernandez R, et al. The necessity of a colonoscopy after an acute diverticulitis event in adults less than 50 years old. Cureus. 2019;11(9):e5666. Published 2019 Sep 16. doi:10.7759/cureus.5666; Carabotti M, Falangone F, Cuomo R, Annibale B. Role of dietary habits in the prevention of diverticular disease complications: A systematic review. Nutrients. 2021;13(4):1288. Published 2021 Apr 14. doi:10.3390/nu13041288; Daniels L, Ünlü Ç, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52-61. doi:10.1002/bjs.10309; Hawkins AT, Wise PE, Chan T, et al. Diverticulitis: An update from the age old paradigm. Curr Probl Surg. 2020;57(10):100862. doi:10.1016/j.cpsurg.2020.100862; Isacson D, Smedh K, Nikberg M, et al. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis. Br J Surg. 2019;106(11):1542-1548. doi:10.1002/bjs.11239; Liu PH, Cao Y, Keeley BR, et al. Adherence to a healthy lifestyle is associated with a lower risk of diverticulitis among men. Am J Gastroenterol. 2017;112(12):1868-1876. doi:10.1038/ajg.2017.398; Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: Expert review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Eswaran was recorded at the 9th Annual Internal Medicine Spring Review, held on May 12-13, 2023, in Plymouth, MI, and presented by the University of Michigan School of Medicine. For more information from this presenter, please visit https://michmed.org/intmedcme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

IM714402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.