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Clear as Mud – Is Your Management of Diverticulitis Evidence-Based?

April 13, 2022

Written by Denrick Cooper

Spoon Feed
There are few studies that address the overall diagnosis and management of acute left-sided colonic diverticulitis; many, over the past 3 decades, have poor strength of evidence or are largely inconclusive.

Why does this matter?
An ongoing debate on the best way to manage acute left sided diverticulitis has been raging (ok, maybe not RAGING…aggressively discussed) for the past decade. For uncomplicated cases, some elect to discharge home, with or without antibiotics. This study sought to improve diverticulitis management by assessing the strength of the evidence that currently exists.

As clear as mud
The authors of this study evaluated acute left-sided diverticulitis evidence over the past 30 years, focusing on strength of evidence, risk of bias, consistency, precision, directness, and limitations. Researchers had 4 topics of interest: diagnostic imaging, outpatient vs inpatient management, antibiotics, and percutaneous IR drainage for abscess formation. This study was done with the support of the ACP and AHRQ, with hopes of making future guidelines.

Six methodologists assessed 34 primary studies in total, 2 systematic reviews and 26 primary studies.

CT imaging

  • Two systematic studies found CT imaging is highly sensitive 94% and specific 99% for diagnosing left-sided colonic diverticulitis.

Outpatient vs Inpatient Management

  • There was no difference in inpatient vs outpatient management for the risk of elective surgery (OR 0.76, 95%CL 0.21-2.77) or recurrence (OR 0.85, 0.50 – 1.43). This evidence, however, was deemed low in strength. The evidence was also inconclusive for risk of death, treatment failure, emergency surgery, and quality of life.

Antibiotics vs no antibiotics

  • There was no difference in treatment with antibiotics vs no antibiotics based on LOS, need for surgery, complications, treatment failure, quality of life, or recurrence. This evidence was deemed low in strength. The evidence was inconclusive based on death, rehospitalization, adverse events and which antibiotic regime to use.

IR drainage of abscess

  • There was an insufficient amount of data to make conclusions on the benefit of IR drainage.

This systematic review focused on the management of acute left-sided, uncomplicated diverticulitis.  It leaves room for research into more complicated cases with patients that are critical or have multiple comorbidities. That said, I left reading this article with more questions than answers. Many of the studies done on uncomplicated diverticulitis were inconclusive, with poor methodology or weak evidence. The article suggests that we may be able to forgo antibiotics in uncomplicated diverticulitis and manage as an outpatient, but even that evidence was weak. It supports the old research adage “Crap in, crap out” – no offense to the colon, of course. I don’t think this article will change my current practice, but it should elicit a call for more robust, well-designed research on diverticulitis.

Another Spoonful
Thanks to JF reader Dr. Dunne for this tip. The AGA recently released an expert review of diverticulitis as well with some discussion and nuance not covered in this review.

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review. Ann Intern Med. 2022 Mar;175(3):379-387. doi: 10.7326/M21-1645. Epub 2022 Jan 18.

What are your thoughts?