WATCH: Clarifying Diverticulitis: Insights from a Multidisciplinary Roundtable

In a recent roundtable discussion, a multidisciplinary panel of experts gathered to discuss evolving perspectives on diverticulitis. Moderated by Dr. Eamon Quigley, chief of Gastroenterology at Houston Methodist, the roundtable features gastroenterologist Dr. Neha Mathur, colorectal surgeon Dr. Tareq Kamal and diagnostic radiologist Dr. Jett Brady.

The conversation offers a comprehensive, evidence-based update on the diagnosis and management of diverticulitis — an area that Dr. Quigley notes has historically suffered from a lack of robust research.

Diverticulum are common — diverticulitis is not

For starters, Dr. Mathur distinguishes diverticulosis from diverticulitis, a distinction known by clinicians but often not patients.

Diverticulosis is common and often asymptomatic, discovered incidentally during colonoscopy. "Just by having a pocket called a diverticulum does not mean that you're going to have symptoms," Dr. Mathur explains. While diverticulosis affects up to 50% of individuals over age 50, only 4% to 5% develop diverticulitis.

CT imaging: The diagnostic cornerstone

CT imaging remains the gold standard for diagnosing diverticulitis. "There are indications where, let's say the patient's pregnant, you might do MRI, you might do ultrasound," adds Dr. Brady. "But CT is by far the mainstay."

If clinical presentation suggests a high probability of diverticulitis — as opposed to kidney stones, for instance — Dr. Brady advocates forgoing oral contrast for intravenous contrast in order to enhance sensitivity for making the right diagnosis and optimizing ER throughput.

Antibiotics are a shifting paradigm

The panel also discusses the evolving role of antibiotics — specifically, in uncomplicated diverticulitis. Dr. Mathur cites randomized controlled trials (AVOD and DIABOLO) showing no significant benefit from antibiotics in uncomplicated cases: "There was no benefit as far as reducing recurrence, complications, hospital length of stay or future mortality," she says.

This shift can present a challenge for clinicians, though, since patients often do expect to be treated with antibiotics.

"I think it's important to differentiate those patients," says Dr. Kamal. "Are they acutely ill with the diverticulitis? Do they have a fever or severe tenderness? Or is this more like a smoldering diverticulitis that's persisting? Because a lot of these patients have already had multiple courses by the time I see them, and they don't need another course of antibiotics. They just need to get over that acute phase and then probably seek surgical treatment."

Managing complications

Complicated diverticulitis — characterized by abscesses, perforations or fistulas — requires nuanced management. Dr. Brady outlines imaging findings, including abscess size thresholds and signs of fistula formation. Dr. Kamal emphasizes a conservative approach when feasible: "Our preference is to get over this acute phase conservatively, with drainage antibiotics, and to come [back] at a later date," he says.

For patients requiring surgery, timing is critical. "We'd like to wait roughly about six to eight weeks from their previous episode, just to allow the inflammatory process to settle down," Dr. Kamal explains. "That improves their chances for a primary colorectal anastomosis. Patients tend to do very well with this minimally invasive surgery. They have an enhanced recovery, and that makes the recovery process for the patient much easier."

Dr. Kamal also stresses the importance of ruling out malignancy in cases involving fistulas, indicating that these patients need to have a recent colonoscopy and cystoscopy to rule out a bladder tumor.

Cancer risk and surveillance

The panel also addresses the hotly debated link between diverticulitis and colorectal cancer.

Dr. Mathur clarifies: "For acute, uncomplicated diverticulitis, I don't think you need a colonoscopy as long as they're up to date on their screening."

However, complicated cases warrant follow-up: "For these really complicated fistula or perforated diverticulitis, that risk of malignancy is higher," says Dr. Mathur. "Within one year they should have a colonoscopy."

Dietary guidance post-recovery

The discussion concludes with dietary recommendations. Dr. Mathur dispels myths around avoiding seeds and nuts: "Those types of foods have a lot of fiber and that can actually help our patients." She recommends at least 25 grams of fiber daily, and Dr. Quigley notes that, in Texas, the average fiber intake is well below that.