Anne Peery, MD, on AGA’s Clinical Practice Update on Colonic Diverticulitis

The American Gastroenterological Association released a clinical practice update last month on the management of colonic diverticulitis, which includes 14 best practices recommended for diagnosing and treating this disorder.

Lead author of the update, Anne Peery, MD, from the University of North Carolina, agreed to answer some questions for Gastroenterology Learning Network about the specific of the recommendations and the changes it reflects from previous guidance.

Gastro Learning Network: The update document states that you have developed 14 best practices for gastroenterologists to follow in managing diverticulitis. What changes do they include from previous clinical reviews?

Anne Peery, MD: There’s been a lot of new research in diverticulitis in recent years, and we were excited to be able to talk about areas that weren’t included in prior reviews. Specifically, we offer additional guidance on treatment of diverticulitis patients who suffer from chronic symptoms, whether to use antibiotics for diverticulitis, when to perform a colonoscopy, and how to counsel a patient considering elective colectomy. 

GLN: The abstract to your document notes that whether patients with diverticulitis should have a colonoscopy after an episode depends on a number of factors. What are those factors, and which are most important to consider in determining whether a patient should have a colonoscopy?

Dr Peery: The first decision point is whether the patient had complicated or uncomplicated diverticulitis. Colonoscopy should be performed 6 to 8 weeks after an episode of complicated diverticulitis or after a first episode of uncomplicated diverticulitis. A colonoscopy could be deferred if a recent (within 1 year) high-quality colonoscopy was performed. Patients with recurrent uncomplicated diverticulitis should follow routine colorectal cancer screening and surveillance intervals. If alarm symptoms are present, a colonoscopy should be performed.

GLN: Why is computed tomography often needed to get a firm diagnosis of diverticulitis? What other types of tests and imaging are advised?

Dr Peery: It is difficult to make a diagnosis of diverticulitis based solely on history, exam, and laboratory data. Unfortunately, clinical suspicion alone is correct in only 40% to 65% of patients. Computed tomography should be considered to confirm the diagnosis in patients without a prior imaging-confirmed diagnosis and to evaluate for potential complications in patients with severe presentations.

GLN: In respect to treating diverticulitis, you note that “elective segmental resection should not be advised based on the number of episodes.” What are the key indicators gastroenterologists should look for when deciding if surgery is necessary for a patient?

Dr Peery: In the past, elective colectomy was recommended after one or two episodes of diverticulitis. Surgical guidelines now recommend an approach that is more conservative and patient centered, and the number of episodes alone should never guide the decision to pursue elective colectomy. Immunocompetent patients with recurrent uncomplicated diverticulitis are often surprised to learn that their chronic symptoms may not go away with colectomy while the procedure puts them at risk for ostomy and other complications. There’s a lot to consider for different patient groups, but helping patients make a decision to pursue or defer surgery requires discussion of diverticulitis severity, co-morbidities, patient preferences and values, as well as risks and benefits.

GLN: You also mentioned that genetic factors can contribute to the risk of developing or having recurrence of diverticulitis. What are these genetic factors?

Dr Peery:  Approximately 40% to 50% of diverticulitis risk is attributed to heritable effects. Gene variants associated with diverticulitis risk include PHGR1, FAM155A, CALCB and S100A10. These variants have effects on epithelial function, smooth muscle and nerve function, and connective tissues.

GLN:  The traditional first-line treatment for diverticulitis is antibiotic therapy. However, you advise that antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis. Does this mean it may not be advisable to treat a diverticulitis patient with antibiotics?

Dr Peery: Treating an immunocompetent patient with mild uncomplicated diverticulitis requires shared decision making. It’s important to acknowledge that we’ve used antibiotics to treat diverticulitis for decades. However, several recent studies found no benefit of antibiotic treatment in immunocompetent patients with mild uncomplicated diverticulitis. Based on this evidence, guidelines across the world now recommend selective use of antibiotics given the potential harms of these drugs and growing antibiotic resistance.

Reference:

Peery AF, Shaukat A, Strate L. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Clin Gastroenterol Hepatol Published online December 3, 2020. https://www.gastrojournal.org/article/S0016-5085(20)35512-8/fulltext#%20