AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis

Key points

Overview

This American Gastroenterological Association (AGA) update offers practical, evidence-based advice for clinicians caring for patients with colonic diverticulitis. It covers diagnosis with imaging, colonoscopy after an episode, selective use of antibiotics, prevention of recurrence and the role of elective surgery, with an emphasis on individualised decisions.

Diagnosis and colonoscopy

Computed tomography (CT) should be considered to confirm the diagnosis in patients without prior imaging confirmation and to look for complications in severe presentations; imaging should also be considered in patients who fail to improve, are immunocompromised or have multiple recurrences and are considering prophylactic surgery. Colonoscopy is advised after complicated diverticulitis and after a first episode of uncomplicated diverticulitis, but can be deferred if a high-quality colonoscopy was done within the past year. It should be considered sooner if alarm symptoms are present. In patients with chronic symptoms after diverticulitis, ongoing inflammation should be excluded with both imaging and lower endoscopy; if none is found, visceral hypersensitivity should be considered.

Acute treatment

A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis, advancing as symptoms improve. Antibiotics are advised in uncomplicated diverticulitis when patients have comorbidities or are frail, have refractory symptoms or vomiting, or have C-reactive protein above 140 mg/L or a baseline white blood cell count above 15 × 109 cells/L. They are also advised in complicated diverticulitis and in uncomplicated disease with a fluid collection or a longer segment of inflammation on CT. Immunocompromised patients are more likely to have severe or complicated disease and warrant a low threshold for cross-sectional imaging, antibiotics and colorectal surgical consultation.

Preventing recurrence

Patients should eat a high-quality diet, achieve or keep a normal body mass index, be physically active and not smoke, and should avoid regular use (two or more times per week) of non-steroidal anti-inflammatory drugs, except aspirin prescribed for secondary cardiovascular prevention. About 50% of the risk of diverticulitis is attributable to genetic factors.

Elective surgery

Complicated diverticulitis is most often the first presentation, and its risk decreases with recurrences. The decision about elective segmental resection should be personalised, considering disease severity, patient preferences and values, risks and benefits, including quality of life. Surgery reduces but does not eliminate the risk of diverticulitis, and chronic gastrointestinal symptoms do not always improve after it.

Frequently asked questions

Does every patient with diverticulitis need antibiotics?

No. In immunocompetent patients with mild uncomplicated diverticulitis, antibiotics can be used selectively; they are advised in frail or comorbid patients, in complicated disease and when specific laboratory or CT findings are present.

When should colonoscopy be done after an episode?

After 6-8 weeks or once symptoms have completely resolved, whichever is longer, unless alarm symptoms call for earlier evaluation.

Should surgery be offered after a certain number of episodes?

No. The number of episodes alone should not drive elective resection; the decision should be individualised.

Source

American Gastroenterological Association. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology, published online December 2020. doi:10.1053/j.gastro.2020.09.059. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.