Cleveland Clinic Journal of MedicineAcute Left-sided Colonic Diverticulitis: A Surgeon’s Perspective on the ACP Guidelines

A comprehensive commentary on the ACP guidelines and what they change.

The American College of Physicians (ACP) updated guidelines on acute left-sided colonic diverticulitis offer new perspectives on management strategies. This has been necessitated by a growing consensus on a less aggressive approach to handling uncomplicated cases of the disease.

Key Points:

• ACP guidelines suggest less-aggressive management of uncomplicated diverticulitis, emphasizing the need for abdominal computed tomography (CT) in cases with diagnostic uncertainty.
• Outpatient management is suggested for most cases of acute uncomplicated left-sided colonic diverticulitis.
• In selected uncomplicated cases, initial management without antibiotics is advocated.
• After an initial episode of complicated diverticulitis, patients are advised to undergo a colonoscopy if they haven’t had one recently.
• Elective surgery to prevent recurrent diverticulitis should be discussed with patients with persistent or recurrent disease or complicated diverticulitis.

Additional Points:

• Inpatient and outpatient outcomes for uncomplicated diverticulitis showed no statistically significant differences in readmission rates, need for emergency surgery, or quality of life.
• Using antibiotics to treat diverticulitis has been questioned, with recent evidence supporting selective use of antibiotics.
• Patients deemed fit for outpatient management also meet criteria for management without antibiotics, but higher-risk patients should still receive antibiotics.
• Patients with 2 or more bouts of uncomplicated diverticulitis saw a 15% recurrence rate at 5 years after elective sigmoidectomy, compared with 61% for those treated nonoperatively.

Conclusion:

• The updated ACP guidelines highlight the need for a balanced approach in managing diverticulitis, stressing the importance of less invasive measures, judicious use of antibiotics, and consideration of elective surgery in select cases.

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Did You Know?
Diverticulitis affects about 200,000 people in the US annually.