EM:RAP 2020 May SNACK: Diverticulitis

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Ian L. -

Attacks of Diverticulitis are often due to having large banquet meals in my clinical experience and I treated patients with oral rehydration fluids and antibiotics in those who refused hospital . -Antibiotic Dose was IM ceftriaxone with 2ml 2 % OR 3.5 ml 1 % xylocaine -as with sterile water it is very painful . -I also used this in Nursing home or special accommodation home patients with mild pneumonia cellulitis or suspected urinary infectionwhen it was late at night --they really wanted a trial of avoiding hospital for the night hours at least . -As follow up the Hospital in the Home Team would be called in the next day .

Sid W -

I had first heard of this idea of not treating divericulitis with antibiotics when Ryan Radecki discussed it on his twitter feed when this Netherlands study came out. I still struggle with the definition of "uncomplicated diverticulitis." I have tried to find data on how good CT is at demonstrating microperforation from diverticulitis. I am not a lit search guru, mind you, but I have not been successful in identifying sensitivity and specificity of CT for micro/small perforation. In the Netherlands study, they included patients with Hinchey category 1b diverticulitis (diverticulitis with pericolic and mesenteric abscess), so maybe the issue of microperforation is moot if they demonstrated safety even with these patients (there were about 40 patients with abscess in both arms).

All that said, and you wisely mention this, you need to be careful about introducing this as part of your practice if your consultants and primary care providers are not on board. The AGA 2015 recommendation is "conditional" and cites "low quality evidence" (obviously does not have 2017 data). There has been, in my opinion, very little discussion of this practice option anywhere, and you are sure to puzzle follow up providers with your decision, unless you are communicating closely with them. Also, you need to make sure the exclusion criteria are not met in your patient from the 2017 study.

I personally haven't implemented this strategy yet. Having seen several patients in septic shock from perforated diverticula in my career, I am still hesitant to try this. But I could see it in a 1st time healthy patient, who really doesn't like medications....I could have a conversation with them about this as an option. Thanks for discussing. -Sid

David S. -

I have avoided antibiotics in uncomplicated diverticulitis on multiple occasions and for quite some time. The key, for me, is to get “buy in” from the patient and the gastroenterologist or colorectal surgeon providing follow up.

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EM:RAP 2020 May SNACK: Diverticulitis Full episode audio for MD edition 7:18 min - 8 MB - M4AEM:RAP 2020 May SNACK: Diverticulitis 11 MB - MP3