40 y/o obese Hispanic M with no PMHx , who presents to the ED with RLQ abdominal pain x 5 days. The pain is 6/10, sharp, non-radiating, and is worse with movement. Patient took over the counter pain med with no relief. Patient states he has never had similar symptoms in the past and is concerned it may be appendicitis, so he came to the ER to get evaluated. Patient is also reporting subjective fevers and chills and one episode of diarrhea yesterday. Patient denies any N/V, blood in the stool, CP, SOB, trauma to the abdomen, recent travel, loss of appetite, sudden weight loss, night sweats, constipation, urinary symptoms, blood in the urine.

The article I chose for the management of this patient was a review article of contemporary literature, which attempts to summarize  the newer trends in approach and management of diverticulitis. Their main goal was to help provide guidance to the clinician decision making process.

According to this article diverticulitis management has been a challenging for clinicians/surgeons, especially since its symptom progression and complications are still not fully understood. There is a huge amount of debate over the optimal management of diverticulitis, with a trend that’s leaning towards conservative treatment with respect to hospital admission and antibiotic treatment.

Topics examined in this article included:

Medical management with antibiotics:

• Some clinicians are challenging established doctrines of antimicrobial therapy in acute diverticulitis
• Cochrane Review in 2014 concluded that there was insufficient evidence to ensure the safety of omitting antibiotics and hence did not mandate a change in clinical guidelines at that time
• The AVOD study, a randomized controlled trial of 623 found m They found that antibiotic treatment neither accelerated recovery nor reduced complications (sigmoid perforation or abscess formation) – Evidence form the AVOD study was incorporated in the “2017 American Gastroenterological Association (AGA) Institute Guideline on the Management of Acute Diverticulitis” which promotes selective individualized as opposed to routine use of antibiotics in this presentation

Use of Mesalazine and Probiotics:

Studies were of insufficient level of evidence to draw meaningful conclusions.

Surgical management:

The article provides easy to follow algorithm for its proposed treatment of diverticulitis based on severity.

F/U (interval) colonoscopy:

– Studies show that interval colonoscopy following an episode of simple uncomplicated diverticulitis is debatable, but endoscopic evaluation after an episode of complicated diverticulitis is essential.

The authors concluded that there should be and individualized approach to each patient depending on the specifics of presentation. They also explain that the is a need for further high-quality research to better understand and improve the management of diverticulitis.

 

Current Controversies in the Management of Diverticulitis: A Review

 

Nally, D. M., & Kavanagh, D. O. (2018). Current Controversies in the Management of Diverticulitis: A Review. Digestive Surgery.doi:10.1159/000488216