Foreword on diverticular disease guidelines for Gut
Diverticular disease is to us gastroenterologists as irritable bowel is to our colorectal colleagues: we see it, but don’t know the best way to treat it. Diverticulosis is an extremely common finding in our colonoscopies, to the extent that we may mention it only in passing when writing the colonoscopy report, or omit it as a dermatologist might not comment on wrinkles on the skin of her patient. However, it is something that our patients will want some advice and guidance on, and there has been no shortage of historical advice given to our patients in the past, based on well-intentioned speculation rather than evidence. Based on NICE’s new guidance we now can tell people with diverticulosis that the condition is asymptomatic and no specific treatments are needed. There is no need to avoid seeds, nuts, popcorn or fruit skins, and a healthy, balanced diet should include whole grains, fruit and vegetables; increase gradually with plenty of water to avoid bloating.
We as gastroenterologists do see milder cases acute diverticulitis, but it is of the sort that does not bring the patient to hospital. If they are admitted, there is evidence-based advice here for our colorectal colleagues for when investigation is required (usually CT) and when intravenous antibiotics are needed. If percutaneous drainage is available and anatomically feasible it should be considered for abscesses of 3cm or smaller, alongside a discussion with the patient about the risks and benefits of surgery. What of perforation? If there is generalised peritonitis, laparoscopic lavage may be offered if there is appropriate expertise, but if faecal peritonitis is identified intraoperatively, proceed to resectional surgery. For recurrent diverticulitis, we should consider open or laparoscopic resection for elective surgery or in people with stricture or fistula.
Lastly, aminosalicylates are not licensed to treat diverticulitis in the UK and there is little evidence to support their use; the same goes for the use of antibiotics to prevent recurrent diverticular disease.
Dr John O’Donohue
Secretary, Colorectal Section, BSG
Co-opted BSG member of the NICE / National Guidelines Centre Committee for Diverticular Disease