The classic teaching for the treatment of diverticulitis includes:
- Hospital admission
- Bowel rest (NPO)
- IV fluids
- Broad spectrum IV antibiotics
This article from Annals of EM in the "Best Available Evidence" series summarizes the existing literature well. Plus, I was one of the journal reviewers for the article and am thrilled to see this coming out in print finally.
Word of caution: This paper only provides guidelines, based on the limited evidence out there. Still use your common sense. For instance, I'd still admit patients who are elderly (>80 years old) or have evidence of any perforation on CT. If on the fence, admit the patient.
Still it's nice to see that the treatment of uncomplicated diverticulitis on an outpatient basis has some supporting literature.
Reference
Friend K, Mills AM. Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis? Annals of Emergency Medicine. 2011 - in early press. DOI: 10.1016/j.annemergmed.2010.11.008
Oh, this one is so good! I want to send these folks home, but did not have a good schema until now.
ReplyDeleteHey Scott: Thanks! Good to know that I'm not the only one who has been trying to figure out a way to justify sending uncomplicated diverticulitis patients home. A lot revolves around common sense, but now the early literature support us.
ReplyDeleteInteresting to see this in the Emergency Medicine literature. Primary care physicians and gastroenterologists in the outpatient setting have been treating diverticulitis with oral antibiotics for many years, without obtaining CT scanning. This is especially true in patients with a history of diverticulitis. Of course the same criteria apply, taking PO, clinically well, no major co-morbidities, no signs of generalized peritonitis on exam, and with instructions that if they were to worsen they should come back to clinic or present to an ED for admission. I understand it's different in the ED where you don't have the benefit of knowing the patient over time. Still, it's very clear that not every patient with diverticulitis needs to be admitted, especially the excellent absorption of oral fluoroquinolones.
ReplyDeleteHi Roger: Thanks for your insight. It sounds like you are an internist? Helpful to hear a different perspective. With a history of prior diverticulitis, it makes sense to treat with po as an outpatient. One could make a case that the ED may be dealing with slightly different patients in that they might be sicker because they were unable to wait to see their PMD because of their pain, fevers, vomiting, feeling too ill...
ReplyDeleteRegardless, I think this is just another case of the literature lagging behind our experiences. Thanks for insight!
Like Roger I've been doing this for a long time in selected patients (from the ED) and am glad to see a consensus document to help support the practice. I would just add that I learned from my 1 year of surgery training that the majority of diverticulitis is by definition a perforation event--and I've successfully treated many a (young, otherwise healthy) patient at home with localized evidence of perforation (little bit of free air surrounding the colon) on CT scan. If I can get away with it though, I try not to CT patients if I think the clinical picture overwhelmingly supports this diagnosis.
ReplyDeleteDan, I too am finally feeling more justified and comfortable with sending patients home even with CT-evidence microperforation. In the 4th study on the card by Etzioni et al, perforation on CT did NOT correlate with outpatient treatment failure. Thanks for your insight.
ReplyDeleteDr. Lin, I'm a resident at Emory. Thought you would be interested in this study, Chabok et al. (PMID: 22290281). Basically no difference in outcomes for acute uncomplicated diverticulitis comparing patients prescribed ABx vs. No ABx (pretty radical Swedish RCT). It was an inpatient study, but kinda makes me feel better discharging patients with an Rx for Diverticulitis knowing full well that a large proportion (many of whom won't fill the Rx anyway) probably will be fine with a little bowel rest. Seems like a healthy person's body tends to do a good job walling off those micro-perforations with or without our help.
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