Little consensus on management of acute diverticulitis

Last Updated: 2015-07-20

By Will Boggs MD

NEW YORK (Reuters Health) - An international panel of experts could agree on only a third of the proposed statements regarding the management of acute diverticulitis, leaving open such issues as antibiotic treatment and surgical approach.

Although the management of acute diverticulitis has evolved significantly over the past decade, there is still controversy over how to manage uncomplicated and complicated episodes.

Dr. D. Peter O'Leary and colleagues, from Galway University Hospital in Ireland, engaged 54 surgeons (identified on the basis of number of publications related to acute diverticulitis) in a Delphi study that sought to achieve international consensus on the management of acute diverticulitis.

Starting out with 63 statements under 12 headings, after three rounds they managed to reach consensus on only 20 statements, according to the July 15 JAMA Surgery online report.

They agreed that computed tomography of the abdomen and pelvis is best for gauging the severity of acute diverticulitis, but they reached no consensus regarding oral and rectal contrast. They also gave little credence to the use of standard x-rays.

The experts supported the use of white blood cell count, neutrophil count, and C-reactive protein level as laboratory markers, while discounting the value of lymphocyte and platelet counts.

U.S. respondents favored the use of antibiotics for uncomplicated diverticulitis, whereas no consensus was reached among respondents from Europe, the UK, and Ireland.

The experts also fell short of consensus regarding the use of probiotics and the use of a high-fiber diet or dietician in the follow-up of patients with acute uncomplicated diverticulitis.

The decision to proceed to surgery for acute uncomplicated diverticulitis is multifactorial and not influenced by such criteria as number of episodes, patient age, or other factors, the experts agreed, and a laparoscopic approach should be used when appropriate.

As for complicated diverticulitis, the experts agreed that the choice of surgical approach depends mainly on the degree of sepsis, but they only achieved consensus that the Hartmann procedure should be used in the setting of feculent peritonitis.

"This study demonstrates that there is more nonconsensus among experts than consensus, even in the same region, on most issues," the authors concluded. "It also provides an excellent snapshot of the status quo in the treatment of acute diverticulitis as well as important directions for future research."

Dr. O'Leary did not respond to a request for comments. But the lack of consensus his group found was also reflected in comments from several experts who did not participate in the study.

Dr. Daniel Isacson, from Vastmanland Hospital Vasteras, Sweden, who participated in the AVOD study, told Reuters Health by email, "No one with uncomplicated diverticulitis should receive antibiotics unless immunocompromised or systemically unwell. We recently published a study looking at this policy in practice following the AVOD study, and noticed to our delight that more than 90% of our patients were treated without antibiotics and we had a complication rate of less than 3%."

"As for surgery, we have a very conservative policy in Scandinavia where we only perform surgery for uncomplicated diverticulitis if it has a significant impact on the patient's lifestyle," Dr. Isacson said. "The people who undergo surgery are few and far between unless they've had a complication."

Dr. Francisco Javier Medina Fernandez, from University Hospital Reina Sofia, Cordoba, Spain, told Reuters Health by email, "The statement 'uncomplicated diverticulitis can be managed safely in the outpatient setting' should be taken cautiously as studies supporting this idea had strict inclusion criteria. Therefore, 'in selected cases' should be added to that recommendation."

"In no moment did the authors refer to percutaneous drainage for the treatment of complicated acute diverticulitis," Dr. Medina Fernandez said. "This radiologic tool may cure abscesses that are not candidates for therapy with antibiotic alone, especially those greater than 5 cm. The inclusion of this therapeutic tool may diminish the number of emergency surgeries. In the modern era, the role of percutaneous drainage should have been addressed in a study of such impact."

"Although some recommendations can be established for the management of acute diverticulitis, most of the decisions on clinical practice should be made in an individual case basis," Dr. Medina Fernandez concluded.

Dr. Luca Stocchi, from the Cleveland Clinic, Ohio, who has published extensively on the management of diverticulitis, told Reuters Health by email, "Perhaps the most important result of this paper is the finding of persistent differences in several important aspects of the disease management among experts."

For example, he said, "While there was agreement that the indication for surgery is multifactorial, the specific indications for surgery were more controversial - for example, if surgery should be recommended after three or four attacks of uncomplicated disease, or whether a colonoscopy is mandatory after an attack of uncomplicated disease, the role of antibiotics alone for diverticular abscesses of less than 4 cm, or the use of laparoscopic lavage in complicated disease."

"There are areas where the existing guidelines should be updated, for example, removing the mandatory use of antibiotics for uncomplicated disease," Dr. Stocchi said. "This particular practice is difficult in the USA, in part because of pressure from patients and referring physicians themselves. There are other areas where the controversy more closely reflects inconclusiveness of the current data, for example, in the role of laparoscopy in complicated diseases or antibiotics for large diverticular abscesses, which can also be influenced by availability of effective interventional radiology services."

"This paper highlights the increasing role of nonoperative management of diverticulitis and has the merit of showing the changes in practice that have occurred throughout the world, despite continued areas of controversy," Dr. Stocchi concluded. "Future studies should address such areas and foster inclusion of stronger data into the current recommendations."

SOURCE: http://bit.ly/1LydbAm

JAMA Surg 2015.