433 - Diverticulitis Update, Cardiac Stress Tests, Feeling Understood
Take 3 – Practical Practice Pointers©
From the Guidelines and the American College of Physicians (ACP)
1) Diagnosis and Management of Acute Diverticulitis
The prevalence of diverticulosis in the US is age-dependent, increasing from less than 20 percent at age 40 to 60 percent by age 60. Approximately 95 percent of patients with diverticula have sigmoid diverticula. An estimated 5-10% of those with diverticulosis may develop acute diverticulitis, and the risk increases with age.
Acute diverticulitis is usually uncomplicated (causing only localized inflammation). However, in about 12% of cases, patients have complicated diverticulitis, which is defined as inflammation associated with an abscess, a phlegmon, a fistula, an obstruction, bleeding, or perforation. The reported rate of recurrence at 10 years is 22%.
Timely and correct diagnosis of acute left-sided colonic diverticulitis is essential for the selection of the most appropriate management options. Abdominal CT imaging is widely used to evaluate persons with suspected diverticulitis. However, questions exist about the diagnostic accuracy, effect on clinical management and diverticulitis-related health outcomes, downstream consequences of incidental findings, and costs of CT imaging. Management of uncomplicated diverticulitis has typically included bowel rest, fluids, and antibiotics, although there is uncertainty regarding the effectiveness of the routine use of antibiotics and the role of hospitalization in managing most episodes.
The American College of Physicians (ACP) recently released a guideline for the diagnosis and management of acute diverticulitis. It is based on current best evidence of benefits and harms in the context of costs and patient values and preferences.
· Use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute diverticulitis (conditional recommendation; low-certainty evidence).
· Manage most patients with acute uncomplicated diverticulitis in an outpatient setting (conditional; low-certainty). Uncomplicated diverticulitis is characterized by absence of frank perforation, obstruction, fistula, or abscess on CT.
· Initially manage select patients with acute diverticulitis without antibiotics (conditional; low-certainty).
For adults with recent episodes of acute left-sided colonic diverticulitis:
· Refer for a colonoscopy after an initial episode of complicated diverticulitis for those who have not had recent colonoscopy (conditional; low-certainty).
· Do NOT use mesalamine to prevent recurrent diverticulitis (strong; high-certainty).
· Discuss elective surgery to prevent recurrence after initial treatment in those who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional; low-certainty). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences.
I was surprised to learn that the 2015 American Gastroenterology Association Guideline (and 2020) on the management of acute diverticulitis also recommended that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis with the emerging belief that acute diverticulitis may be more inflammatory than infectious. This recommendation was also with low quality evidence (though so is the present practice of routinely using antibiotics for uncomplicated disease!).
While changing practice is challenging and my experience is that most clinicians (and patients) have a bias toward treatment/intervention, it’s nice to know that is a reasonable option, particularly in patients who are resistant to talking antibiotics. If antibiotics are indicated in the ambulatory setting, amoxicillin-clavulanate alone should be favored over combination of fluoroquinolones and metronidazole due to the FDA advisement regarding reserving fluoroquinolones for conditions with no alternative treatment options.
· Quaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med 18 January, 2022. Link
· Quaseem A, et al. Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med 18 January 2022. Link
From the Literature and a Podcast
2) Choice of Stress Testing for the Evaluation of Chest Pain
There is an increasing number of choices for cardiac stress testing to diagnose coronary artery disease (CAD) these days. How can we make the best choices about what to order? A recent internal medicine podcast summarized the evidence in a non- systematic, but useful way.
There are two parts to stress testing: the stress component (exercise or pharmacologic) and the diagnostic component (EKG, echocardiography, nuclear medicine, PET/CT, MRI, etc.).
· If the patient can exercise, they should have an exercise stress test, otherwise choose a pharmacologic stress. The pharmacologic agents include adenosine, dipyridamole, regadenoson (vasodilators; don’t use them with broncho-constrictive disorders or heart blocks without a pacemaker) and dobutamine (inotropes; don’t use in a patient with ventricular arrythmias).
· with exercise stress, sensitivity 61-68%, specificity 70-77%
· if the baseline EKG is abnormal (digoxin, left bundle branch block, etc.) choose an imaging-based mode below.
· with exercise stress & EKG, sensitivity 70-85%, specificity 77-89%
· helpful to evaluate valve pathology, pulmonary hypertension or left ventricular
· outflow tract obstruction
Nuclear single-photon emission computerized tomography (SPECT)/Myocardial perfusion imaging (MPI)
· with exercise stress, sensitivity 82-88%, specificity 70-88%
· with pharmacologic stress, sensitivity 88-91%, specificity 75-90%
· can miss global ischemia (from left main coronary artery disease, etc.)
· with pharmacologic stress, sensitivity 92-93%, specificity 83-85%
· costly and not widely available.
Cost increases as you go down this list, but sensitivity increases. Since we are most often doing these to rule out heart disease, sensitivity is more important.
This information is partly based on a systematic review from 2018 that compared the diagnostic tests characteristics of exercise EKG vs. exercise echocardiography vs MPI to look at the diagnostic test characteristics of stress EKG, echo and MPI. In this review, the best likelihood ratio for a negative test (which helps you rule out disease) was only about 0.2, which is good, but not great.
Click for a link to a great infographic from the podcast about stress test options. Just like any diagnostic tests, the results should be interpreted using Bayesian thinking – i.e., by estimating the pre-test likelihood first and using the likelihood ratio to determine the
post-test likelihood. In someone without many risk factors who has atypical chest pain, an exercise echocardiogram (for instance) will reduce a small risk of CAD to a very small risk. For patients with a high risk (lots of cardiac risk factors or convincing symptoms), you will need a more sensitive test (MPI or catheterization) to comfortably rule out CAD.
· Core IM 5 Pearls on Stress Testing – Clinical Correlations. Accessed January 24, 2022. Link
· Banerjee A, Newman DR, Van den Bruel A, Heneghan C. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta- analysis of prospective studies: Exercise stress testing and coronary artery disease. International Journal of Clinical Practice. 2012;66(5):477-492. Link
From PeerRxMed ( www.PeerRxMed.org )
3) I’m Out to Get You – the Power of Feeling Understood
“You know what everybody needs? … Everybody needs to be understood.”
Sherwin Nuland, MD, surgeon, author, bioethicist
When my children were younger, we used to regularly play a game in which I would say to them in a scary voice “I’m out to get you!” and then a chase would ensue, usually ending with us in a pile on the floor laughing. Recently, I’ve been thinking about that game and our human desire to be “gotten” as I’ve found myself sometimes joking with a colleague (without the scary voice or chasing) “I’m out to get you” when I want to better understand them.
Here are two stories that have been shared with me by colleagues who are participating in the PeerRxMed process that powerfully demonstrate the importance of our creating space to understand and be understood – to be gotten.
The first shared a story about the power of creating a space to allow another to feel heard: “I really didn’t want to do the check in. There was just too much going on in my week. If it hadn’t been for your ‘nudge’ e-mail, I wouldn’t have done it. When I texted my PeerRx buddy and asked ‘How are you?,’ they texted back that they were so glad I reached out – that they really needed to talk with someone about a struggle they were having and they didn’t know who else to talk with about it. What resulted was an important phone call where they opened-up about something quite serious they had been grappling with and we talked through it together. I don’t think any of that would have happened had I not reached out. It felt really good to be able to help them.” And I suspect it felt even better to feel helped.
The second story was equally powerful about our need to feel understood. “I had a close relative who had recently died, and I was feeling quite sad about it. When I checked in with my buddy (FaceTime), they asked how I was doing. I initially said that I was ‘fine,’ and then realized I was falling into a default pattern for me around stuffing ‘negative emotions.’ In the spirit of your encouragement to ‘feel what you feel,’ I interrupted that default mode and shared that I was actually not doing fine and was feeling profound sadness over the recent loss of someone whom I loved dearly. What followed was an incredible sharing about how death had impacted each of our lives, and we both found ourselves crying, which I rarely do and never in front of a colleague. We only talked for 15 minutes, but at the end I felt both comforted and so much more deeply connected with them.” Wow ….
Yes, the need to feel understood is an essential part of who we are. There is incredible power when we connect around those things that most deeply matter to us. This week, when someone asks, “How are you?”, allow yourself to be “gotten” a little more by sharing from your sacred “this is really important to me” space, and take a moment to appreciate the gift of having someone in your life who cares enough to be “out to get you.”
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.