Mistakes in ... Booklet 2020 - 9

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Mistakes in... 2019

diverticulitis, initially without abscess or
peritonitis but with free pneumoperitoneum.17
In 29 of the 91 patients (31.9%), conservative
(antibiotic) treatment failed, with failure defined
as the formation of an abscess >4 cm or the
occurrence of peritonitis. Among the 29
patients whose treatment failed, 24 had a
pneumoperitoneum diameter >5 mm. Indeed,
risk factors for failure of conservative treatment
are tachycardia, CRP levels >150mg/mL, pericolic
air with a volume of >5 mm and peritoneal fluid in
the pouch of Douglas.17
The systematic review previously described16
excluded patients with pneumoperitoneum,
defined as the presence of gas within the
peritoneal cavity, which explains the difference
in results between the systematic review and the
retrospective series. The description of "pericolic
extraluminal air" is crucial, because patients with
pericolic extraluminal air caused by acute
diverticulitis can usually be carefully observed
with frequent physical examination, laboratory
follow-up, intravenous antibiotic treatment, and
in case of deterioration repeat abdominal CT.
In conclusion, we believe that the vast
majority of patients with isolated pericolic
extraluminal air caused by left-sided acute
diverticulitis do not need an emergency
intervention. In case of failure of conservative
treatment, characterized by progressive disease,
repeat CT is needed.

Figure 3 | Abdominal CT scans of diverticulitis.
a | Acute diverticulitis with pericolic extraluminal
air. b | Diverticulitis with abscess formation
(Hinchey II). c | Perforated diverticulitis with faecal
peritonitis (Hinchey IV).

Mistake 6 Routine prescription of antibiotics
for patients with acute uncomplicated
diverticulitis

classification is a radiological classification
frequently used to help determine which type
of treatment a patient should receive; however,
pericolic air is not included in the Hinchey
classification and evidence on the natural course
of pericolic extraluminal air visualized by CT is
scarse.
A systematic review and meta-analysis,
ncluding eight studies, evaluated the need
for emergency surgery and the need for
percutaneous abscess drainage during the initial
course of acute diverticulitis.16 In six of the eight
studies, all patients were treated with antibiotics,
in one study only some patients, and in one study
no information was supplied about the use of
antibiotics. An initial 94% success rate (no
need for further treatment) was found for
nonoperative treatment of patients with isolated
pericolic extraluminal air caused by left-sided
acute diverticulitis. This finding is in line with
the tendency to treat patients who have acute
diverticulitis more conservatively, in this case with
antibiotics instead of emergency surgery.
A retrospective observational multicentre
study of conservative treatment was performed
comprising 91 patients with perforated

Probably one of the most frequently made mistakes
when treating patients with acute diverticulitis
is the routine prescription of antibiotics for those
whose diverticulitis is uncomplicated. Certainly,
uncomplicated diverticulitis has been treated with
antibiotics for decades, even though this is not
supported by the literature.
The multicentre randomized DIABOLO
trial has shown that observational treatment
without antibiotics does not prolong the time to
full recovery of patients with CT-diagnosed
left-sided uncomplicated diverticulitis.18 Full
recovery was evaluated by the following criteria:
a normal diet, temperature <38°C, VAS pain score
<4 (no need for daily pain medication), discharge
from hospital and resumption of pre-illness
working activities as assessed by a daily patient
diary. Similarly, the multicentre randomized
AVOD trial from Scandinavia, which also
included patients with CT-diagnosed left-sided
uncomplicated diverticulitis, found that
antibiotic treatment neither accelerated recovery
nor prevented complications or recurrence.19
We believe that patients who have acute
uncomplicated diverticulitis should be treated
without antibiotics and that only in specific cases,
such as immunocompromised patients, should

antibiotic treatment be chosen. The results of the
two RCTs discussed above have been combined to
assess the long-term effects of omitting
antibiotics in this specific patient population.20
After a follow-up of 24 months, treatment of
acute uncomplicated diverticulitis without
antibiotics did not result in more complicated
diverticulitis, recurrent diverticulitis or sigmoid
resections than treatment with antibiotics.

Mistake 7 Routine hospital admission for
acute uncomplicated diverticulitis
As we see no need to routinely prescribe
antibiotics for the treatment of acute
uncomplicated diverticulitis (see mistake 6),
it follows that there is no definite need to admit
these patients to hospital for administration of
intravenous antibiotics. This leads to new
treatment options for this specific population-
outpatient treatment.
A recently performed systematic review and
meta-analysis included more than 2,000 patients
with uncomplicated diverticulitis who received
outpatient treatment. Only 7% of patients had to
be admitted to hospital, 0.2% needed to undergo
emergency surgery and another 0.2% underwent
percutaneous abscess drainage.21 These results
are supported by another study that analysed
more than 1,000 patients with CT-proven leftsided acute uncomplicated diverticulitis, to
find possible risk factors for the developing a
complicated course.8 Less than 5% of all patients
developed complicated diverticulitis, and most of
them within the 10 days of their initial diagnosis.
Patients with a systemic comorbidity, defined as
American Society of Anesthesiologists (ASA) 3 or 4,
who vomited, had symptoms for more than
5 days or an elevated CRP level above 140 mg/L at
initial presentation, had a higher risk of developing
a complicated course of initially uncomplicated
diverticulitis.
With these risk factors in mind, and targeting
patients with sufficient mental capacity to
understand the possible outcomes and what they
need to be aware of, most patients with CT-proven
acute uncomplicated diverticulitis seem suitable
for outpatient treatment. Outpatient treatment
not only benefits patients, who usually prefer to
recuperate at home and not to be admitted to
hospital for observation, it may also help to reduce
healthcare costs.

Mistake 8 Thinking that more aggressive
treatment is indicated for young patients
In the past, diverticulitis was a disease associated
with elderly patients; however, acute diverticulitis
also affects many young patients. Some believe
that young patients have a more severe disease
course and a higher recurrence rate than elderly
patients. The current Dutch national guideline for
acute diverticulitis22 addressed whether young
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