Abstract
Background: We identified areas of controversy in the management of patients with diverticular disease to develop key questions addressing the management of symptomatic uncomplicated diverticular disease (SUDD), uncomplicated diverticulitis, and complicated diverticulitis.
Methods: We performed a systematic review to identify randomized trials and cohort studies addressing our key questions. Informed by an updated evidence synthesis, an international, multidisciplinary panel of gastrointestinal surgeons, gastroenterologists, patient partners, and methodologists applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence-to-decision framework during panel consensus meetings to derive recommendations for the management of patients with diverticular disease.
Results: The systematic review identified 27 studies representing very low to moderate certainty evidence. The panel made the following recommendations: 1. In patients with SUDD, we suggest rifaximin or mesalamine over standard supportive care (conditional recommendation); 2. In patients with uncomplicated diverticulitis, we suggest no routine antibiotics (conditional recommendation); 3. In patients with persistent symptoms following an episode of recurrent uncomplicated diverticulitis, we suggest elective resection over observation (conditional recommendation); 4. In patients who have recovered from a first episode of uncomplicated diverticulitis, we suggest no routine follow-up colonoscopy (conditional recommendation); 5. In patients who have recovered from a first episode of diverticulitis complicated by an abscess, we suggest elective resection over surveillance (conditional recommendation). The panel judged that a significant proportion of patients would place a high value in reducing the risk of recurrence at 1 year but also acknowledged the lack of evidence addressing prioritized outcomes including 30-day major complications, need for emergency surgery, stoma-free survival at 1 year, and quality of life at 1 year. Given that patient values and preferences may vary, clinicians are encouraged to apply patient-centered decision-making and discuss the alternatives.
Conclusion: This clinical practice guideline update provides evidence-informed recommendations to support patients and clinicians in the management of diverticular disease.