← The Curbsiders Internal Medicine Podcast
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- [00:00]
Sponsor/Ad Reader
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool stuff@patreon.com curbsiders.
- [00:19]
Dr. R.J. Blackburn
Moni, Meredith, are you ready for tonight's episode?
- [00:22]
Dr. Moni Amin
Sure as I ever am, I guess.
- [00:25]
Dr. R.J. Blackburn
Well, you better be because it's a gut wrenching episode.
- [00:29]
Dr. Meredith Trubitt
You sold it. You sold it.
- [00:32]
Dr. R.J. Blackburn
I really tried.
- [00:33]
Dr. Moni Amin
You can. You can sell just about anything, rj. All right.
- [00:40]
Podcast Disclaimer Voice
The Curbsiders podcast is for entertainment, education and information purposes only, and the topics discussed should not be used solely diagnosed, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of the host and should not be interpreted to reflect official policy or position of any entity aside from possibly cash, like moral hospital and affiliate outreach programs, if indeed there are any. In fact, there are none.
- [00:54]
Dr. Andrew Webster
Pretty much.
- [00:55]
Podcast Disclaimer Voice
We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.
- [01:00]
Dr. Moni Amin
Foreign. Welcome back to the curbsiders. I'm Dr. Moni Amin, joined by my eternally effervescent co host, Dr. Meredith Trubitt. How are you this evening?
- [01:13]
Dr. Meredith Trubitt
Doing great. I'm here, we're recording.
- [01:16]
Dr. Moni Amin
Yeah. And we've got a twofer this evening, and in that we have two guests on our episode for diverticulitis, Drs. Robert Hollis and Andrew Webster, repeat guest, I might add. And in just a Second, our producer, Dr. R.J. blackburn, will tell you a little bit more about our guests and the topic. But first, Meredith, will you please remind the good people in the audience what it is we do on the show?
- [01:37]
Dr. Meredith Trubitt
Sure, Moni. We are the Internal Medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. Rj, you want to tell us a little bit about the guests?
- [01:47]
Dr. R.J. Blackburn
Tonight we have a fantastic conversation with our guests, Doctors Robert Hollis and Andrew Webster. Dr. Hollis is a colorectal surgeon within the Division of gastrointestinal surgery. Dr. Hollis completed his general surgery residency training and Master's of Science in Public Health at the University of Alabama at Birmingham. Following residency, Dr. Hollis completed a colorectal surgery fellowship at the Cleveland Clinic. Dr. Hollis Clinical areas of expertise include colorectal cancer, hereditary colorectal cancer syndromes, diverticulitis, pelvic floor disorders, including rectal prolapse and benign anorectal conditions. The research that Dr. Hollis performs addresses health inequities by developing and implementing effective interventions. He has a specific focus on improving outcomes of patients with hereditary colorectal cancer syndromes and intervention development for improving transitions of care for patients with a new ostomy. Dr. Andrew Webster is an infectious disease physician at the Atlanta VA Medical center, where he serves as the director of antimicrobial stewardship program. He completed his infectious disease and medical microbiology fellowships at Emory and has particular interest in medical education and diagnostic stewardship. Tonight we talked to Drs. Webster and Dr. Hollis about diverticulitis and in particular, some of the key points we'll be covering antimicrobials and when to do surgery or when to call surgery for complicated cases.
- [03:25]
Dr. Moni Amin
Reminder that this and most episodes will be available for CME credit for all health professionals through VCU Health at curbsiders.vcuhealth.org okay, so with our twofer, we've got two great guests to get to know. Actually, one of our guests, Andrew Webster, Dr. Andrew Webster, we've had before, so may spend a little more time getting to know Dr. Bob Hollis. It's a lightning round. We're just going to ask you a couple of questions to get to know you a little bit better. All right, so, Bob, tell us. One of the things we like to ask people is in either professionally or personally, what's some of the best advice or feedback that you've gotten that you've kind of kept with you?
- [04:09]
Dr. Robert Hollis
Yeah. So as a surgeon, one of the best advice is to know when to go fast and when to go slow. So taking a sigmoid colon out, you wanna be slow around the inferior mesenteric artery. Perhaps you can get a little faster when you're mobilizing the rest of the colon. But, but I think it applies not only in the operating room, but also around everything else you do. You know, you walk into that one patient's room, they're like, they're looking great, like, all right, next room. Other times you need to slow down the next room. And the same when you go home, you know, sometimes your kids are just like brain rotting, watching tv and you're like, all right, I'm gonna go do something else. Other times they're like sitting at the table and like welcoming you to a conversation. So I've taken that one to heart.
- [04:55]
Dr. Meredith Trubitt
That's a good one. And I feel like we haven't had that one a lot on from medicine people. So that, yeah, that's a fun one.
- [05:01]
Dr. Moni Amin
That's great. When you have different flavors coming on the curb. Yeah.
- [05:04]
Dr. Meredith Trubitt
Yeah. What about Any favorite, like, hobbies or interests that you do?
- [05:09]
Dr. Robert Hollis
I'm a golfer and try to pair up, you know, one round whenever I go out to some conferences. And, you know, one fun round out in San Diego is Torrey Pines, a public golf course out there, home to the Farmers Insurance PGA Tournament. And if you go out, you can put your name on a list and you get really lucky. You'll get selected and get to go out, even though, like, people book it out months in advance. So this past May, I went out on a Monday at noon, got on the list, and got called two hours later. They said I couldn't move an inch. So I just put it for two hours straight, and I get called, and it was great. I got to play with a guy from the naval base, a guy who was a bartender downtown and a private equity guy, and I felt like I was in America. Like, paragliders. Like, my group. Sun's out. It was. It was awesome.
- [06:04]
Dr. Meredith Trubitt
That's a really good description of America. Love it.
- [06:07]
Dr. Moni Amin
So good. So good.
- [06:10]
Dr. Meredith Trubitt
Andrew, I know last time you were on, we talked a lot about baseball, but any updates to favorite interests or hobbies?
- [06:15]
Dr. Andrew Webster
I mean, definitely. Still, baseball occupies probably more of my time than it should. It's like, borderline pathologic obsession with the sport. But, no, I mean, aside from base, I do a lot of reading, and it's kind of weird. I bounce between different genres of reading, and currently I'm very much in the high fantasy realm of things. So currently reading a series of five books by Peter Brett called the Demon Cycle, which is just a very fun read. Kind of nice to turn the brain off. So still spend a lot of time with baseball, but the way my Texas Rangers are doing this year, I've been reading a little bit more, especially as the season winds.
- [07:00]
Dr. Meredith Trubitt
Yeah, 23 was different.
- [07:03]
Dr. Andrew Webster
23 was different. Yeah.
- [07:05]
Dr. Moni Amin
It has been a while since you've joined us, so things have changed.
- [07:08]
Dr. Meredith Trubitt
Yeah. You want to do picks of the week? Rj, you want to go first?
- [07:14]
Dr. R.J. Blackburn
I think my pick of the week is literally probably my pick of the week from last time. It's just that it's coming back on, so I think the last time I did this was only murders in the building. And it's coming back on in, like, a week or two, back in September. So I'm just. I'm excited all over again.
- [07:35]
Dr. Moni Amin
Yeah. I think I need to rewash a little bit because it's been a minute. Yeah. It's so good. So good.
- [07:41]
Dr. Meredith Trubitt
I will give everyone the recommendation I gave you and Netflix Nobody wants this. I'm Jewish. But I will say that Moni's been watching it too, because I said that the specificity that they do throughout the, like, throughout the show, I think just applies to everyone's culture. Probably same as Moni making me watch never have I ever on Netflix before this. So both of those great shows, very specific, very funny.
- [08:09]
Dr. Moni Amin
Yeah, I actually watched it after Meredith told me to, especially when she's like, this is kind of like my never have I ever. And yeah, the cultural specificity, you think it would be alienating, but it's actually, like she said, just like very. Actually makes you just feel very seen because it's like all the crazy family dynamics and stuff, they're just like, they happen everywhere. So mine, honestly, I feel bad because I've been talking about it for like a month straight, but the Superman movie that came out this summer is just like brought me so much joy. It's just lovely and light and colorful and just all the things I want in a superhero movie and weird, crazy creatures popping out of the sky. I just like what you want from a Superman movie. And I've just been very happy. I've seen it way too many times in theaters, but that's what happens when the theater is 200ft from your house. So anywho, I could talk about that movie ad nauseam, but instead we will get to Cash like rj, will you take us to our first case, please?
- [09:13]
Dr. R.J. Blackburn
All right, so our first case for a guest from Cash like memorial. So Mr. Colin Idis, a 58 year old male with obesity, a BMI of 35, hypertension and chronic constipation. Presents with left lower quadrant abdominal pain for two days. The pain is constant, crampy worse with movement. He also reports subjective fevers and chills. Decreased appetite but able to drink fluids. Some mild nausea without vomiting, denies any urinary symptoms or rectal bleeding and vital signs are. A temperature of 38.1 C, heart rate of 96, blood pressure of132.78 with a respiratory rate of 16 and SpO2 of 98%. On room air, he is alert but uncomfortable. Abdomen soft but tender in the left lower quadrant with mild voluntary guarding. There's no rebound or rigidity. There are normal bowel sounds with a white blood cell count of 13.5, a creatinine of 1 and a lactate of 1.2. The CT abdomen pelvis with IV contrast shows localized sigmoid diverticulitis with pericolic flat stranding. No abscess, free Air or perforation. So, Andrew, we'll start off with you. Can you define diverticulitis for us? And how do you classify uncomplicated versus complicated disease?
- [10:44]
Dr. Andrew Webster
Yeah, so appreciate the question. It's kind of a nice one. One of the cases in medicine where the name's very descriptive. So diverticulitis is really just inflammation of these pre existing out pouchings of the intestine called diverticula. And so if you have these out pouchings, you have diverticulosis, but when they become inflamed it becomes diverticulitis. So with the root itis meaning inflammation and then diverticula, so you get diverticulitis. So it's a pretty descriptive term in terms of remembering what it means. And I know we'll probably get into some treatment and stuff later, but I do think it's worth mentioning now that diverticulitis really is just indicative of inflammation, not necessarily always indicative of infection. And so you don't necessarily always need antibiotics. But diverticulitis just means inflammation of those pre existing out pouchings. As far as complicated versus uncomplicated goes. So uncomplicated diverticulitis would be localized inflammation that's really confined to the colon wall in local fat without really spread outside those kind of anatomical boundaries. Complicated diverticulitis would be present when there's a progression beyond that local inflammation. And that can present in many different ways. So you may form a localized phlegmon or an abscess, you can have a small perforation, you can develop a stricture or a fistula. So the way I think about complicated diverticulitis is not only do you have that underlying inflammation, but then you have some sort of anatomical disruption or local complication beyond the initial kind of involved area.
- [12:31]
Dr. Moni Amin
Along the lines of sort of definitions and whatnot. What kinds of things do you expect to see exam wise, in terms of is there anything in history or exam that tips you off like this might be complicated versus not, or is this all kind of based on other things that are not in our history and physical.
- [12:50]
Dr. Andrew Webster
Yeah, no, it's a good question. And I mean, I think you can start to get some clues from a history or an exam. And I think there may be some features of history exam that might, you know, increase my suspicion or my concern that there could be complicated disease. But it can be really challenging to distinguish between complicated and uncomplicated diverticulitis just based on history and exam. I think it was Osler who said it's 90%. I think this is one of the cases where that extra 10% is really helpful in trying to define whether or not it's complicated or uncomplicated disease. So, you know, keeping in mind that complicated disease is kind of associated with these anatomic disruptions like perforation or abscess formation, I would typically expect that the symptoms that are, you know, being reported by the patient on presentation might be a little bit more severe. They may include a little bit more systemic manifestations if the patient has underlying comorbidities or immune suppression, like they have cirrhosis or they're on chronic steroid use for, you know, rheumatoid arthritis, or, you know, they're a transplant patient where they may have some difficulties kind of fighting off some of the local bacteria in the setting of this inflammation. That may increase my suspicion that they could progress to complicated disease. Fever can really occur in either case. But maybe the degree or the persistence of fever may also, you know, raise my concern. Someone who says, oh, I run a little cold and I'm 39. You know, I'm 99 degrees now. Okay. Someone who says, I took my temperature over the last two days and I've been 102 consistently. That would be a more concerning feature. As far as the exam part goes, I mean, left lower quadrant tenderness is most commonly what you're going to see. And you may even have some like, localized kind of like guarding over the left lower quadrant. But if they had kind of signs of a more frank peritonitis, so they had like rebound tenderness or more diffuse guarding, that would also increase my concern that there's something causing a more diffuse inflammation, such as a perforation causing more diffuse peritonitis. Rarely. You can even palpate like a mass in the left lower quadrant. As far as exam goes, if you have a large enough abscess or phlegmon, you can sometimes even find that on exam. It's pretty uncommon. So I certainly wouldn't say it's absence rules that out. But those would be the things that might be looking for.
- [15:25]
Dr. Moni Amin
Yeah, and you kind of alluded to this, but those. Some of those things can be somewhat broad and not necessarily so. What sort of lab and imaging testing do you kind of rely on to kind of quench the diagnosis?
- [15:38]
Dr. Andrew Webster
Yeah, and even labs, I think, you know, at times aren't as helpful because, you know, as the name implies, what we're dealing with is inflammation. And so you can get an elevated white blood cell count, you can get elevated inflammatory markers like C reactive protein and and that's not be very specific in terms of saying this is complicated or uncomplicated. I think, again, that the degree of abnormality in those tests may raise the suspicion. So I would think of a patient presenting with these symptoms with a white count of 12 differently than someone presenting with these symptoms with a white count of 20, kind of similar to the fever curve. And so I think the degree of abnormality can maybe start giving you a clue that there's more going on than kind of an uncomplicated diverticulitis. As far as the labs go, you know, if they had something like an elevated lactate, that might also increase my concern that there's something bad happening inside the belly. But really, when it comes down to it, I think CT imaging is really going to be the gold standard that you used to diagnose diverticulitis and confirm your clinical suspicion and also assess for those complications. And really, you're not going to be able to look for all of those kind of anatomical disruptions. You know, you're not going to be able to assess for, you know, obstruction or fistula or abscess or, you know, perforation, really, with anything other than, like a CT scan. So that really is the imaging test that you're going to rely on to kind of clinch both the diagnosis and whether or not there may be complications present.
- [17:11]
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- [20:16]
Dr. Meredith Trubitt
And I think I had read like CRP is also not super indicative unless you're getting like you were saying for the white count like over I think like a 1:50. Then you're kind of like more concerned.
- [20:28]
Dr. Andrew Webster
Yeah, the degree of elevation can definitely kind of. Again, it's not going to be super specific, but I think you can look at some of those thresholds as kind of something that may be pointing towards, you know, maybe I need to be thinking about these complications earlier. Maybe the urgency to get that CT scan to assess for those complications is a little bit higher rather than, you know, just doing the supportive care.
- [20:50]
Dr. Moni Amin
Okay, we didn't have this maybe written out as a question, but I did read a little bit just like thinking through the like admission versus discharge with and we'll get to the antibiotics part. But like how do you think through somebody that needs to be admitted versus somebody that can just go off into the ether?
- [21:09]
Dr. Andrew Webster
Yeah, I mean, I think there are some kind of universal truths to safe disposition. Right. So in someone who has ongoing inflammation where there is risk of developing infection, if it's not already present, what kind of social support do they have? How reliable is their follow up? I think other things you'd want to look at is are there signs of like kind of a systemic illness? So do they have any signs of like impending sepsis? Are they tachycardic? You know, what does their temperature curve look like? Do they have, you know, any, you know, worrisome findings on labs like an acute kidney injury, which might just be associated with disease severity in general. So to me, when you're thinking about disposition, you know, you really have to be careful with your patient selection in terms of discharge versus admission. But I think if you're someone who's immune competent, who really doesn't have a lot of medical comorbidities, who doesn't have any signs of sepsis, and who has good follow up, that would be someone that I would consider a candidate for outpatient management and follow up rather than necessarily admission. I think on the flip side, if they have complicated disease as evidenced by the CT scan, all of those should be admitted because you're going to need to make sure that they're improving.
- [22:24]
Dr. Meredith Trubitt
So I think that's a good segue into our patient, Mr. Itis, who seems like, at least from the description and what we've seen on the imaging, is that this is uncomplicated disease. And so it sounds like maybe could be discharged from the emergency room or from an obs unit, depending on your local practices. And I know we were highlighting this as like inflammation. So maybe the question is who needs antibiotics and if so, which antibiotics?
- [22:54]
Dr. Andrew Webster
Yeah, it's a great question. And so I would agree that in this case this would be uncomplicated disease. And you know, our patient has some comorbidities, but no, no known immune compromise. You know, we don't get any history that this is someone who were particularly worried about follow up. You know, his does have a fever, but it's 38:1. You know, maybe borderline tachycardia, white count, very mildly elevated. It certainly seems like this is someone that should they be improving with kind of supportive care in the ED could be dispoed to home. Now, as far as the question of antibiotics, even the aga, the American Gastroenterological association, basically recommends selective use of antibiotics rather than routine use of antibiotics. And some of the criteria that they outline in their guidelines is basically that if the patient has acute diverticulitis and they're immune competent, they have uncomplicated disease on the left side, they don't have signs of systemic inflammation or sepsis, and they can reliably follow us outpatient. That's the patient population where you could consider monitoring without antibiotic therapy. Now, for Mr. Itis, he has a little bit of a white count, he has a fever, his heart rate's borderline. So I would say in his case, he should be treated based on those kind of systemic signs of inflammation, particularly the fever and elevated white count. Were those absent, you might be able to make the argument in his case that he could go home with supportive care and observation if he's improving in the ED with things like diet restriction or analgesics. But because I think he meets criteria for treatment, I still think he would be someone who you could watch in the outpatient setting. And so when you're looking at the different types of antibiotics that you can use, there's a couple different oral antibiotic regimens which are recommended in guidelines. I think it's important to, you know, anytime you're thinking about empiric antibiotics, which is most abdominal infections are empiric treatment because it's difficult to obtain culture safely. But the type of bacteria that we're worried about treating in this scenario are essentially enteric gram negative organisms. So your E. Coli, your proteus, your klebsiella, as well as anaerobic bacteria. So you want to be sure that whatever regimen you're choosing will include treatment of enteric gram negatives and anaerobic bacteria. And so the common ones that are used would be things like amoxicillin clavulanate, which has good enteric gram negative coverage and anaerobic coverage together as one pill. Other commonly used regimens would be a fluoroquinolone like ciprofloxacin plus metronidazole, because ciprofloxacin wouldn't cover the anaerobes. So you need to add the metronidazole for the anaerobic coverage. Trimethoprim sulfa plus metronidazole can be an option if there's allergies or comorbidities which impact your ability to use some of the other regimens. In my mind, that's a little bit more of like a second line agent. Keeping in mind that I must admit my own personal bias against Bactrim. For whatever reason, I feel like I just always see In Cash Lock Southeast, our patient population tends to be medically frail. A lot of elderly people, a lot of kidney disease. I've seen lots of side effects from Bactrim, so fairly or unfairly, I tend to shy away from it. But I think also just from a reliability of enteric gram negative coverage, I would lean towards a fluoroquinolone plus metronidazole or the amoxclav with my personal preference tending towards Amox clav, both for ease of pill burden, meaning it's one medication which covers both your gram negatives and anaerobes as opposed to needing a separate medication for each, as well as the more favorable safety profile for amoxclav compared with fluoroquinolones. Fluoroquinolones, particularly in an older population, may cause a little bit more side effects. There may be more interactions. You know, there's QT prolongation, There's some increasing concerns about AAAs or aneurysms. There's a JAMA review which actually looked at these two regimens side by side, fluoroquinolone and metronidazole versus amox clav and found there's a higher risk of c.diff at one year in those receiving a fluoroquine alone. And so that would be another consideration. And I think you can also look at your local antibiogram. As someone who does stewardship on a day to day basis, I would be remiss if I didn't find a way to work an antibiogram into this conversation. And so if you just know your resistance patterns of your kind of enterogram negatives, looking at your things like E. Coli, that may also come into play when you're choosing which one of those regimens.
- [27:43]
Dr. Meredith Trubitt
And Andrew, I feel like the length of treatment I have in my mind is like 10 days. But I also feel like we're talking about uncomplicated disease. And I know there's a lot of shortening of courses in other infections, so I'm just wondering if there's any role for something like shorter for these uncomplicated patients.
- [28:02]
Dr. Andrew Webster
Yeah, I tend to go five to seven days and, and I know I, I usually don't like giving a range. I think it really just kind of depends on your overall concern and how the patient looks in front of you. I certainly wouldn't go any shorter than five, I wouldn't go any longer than seven. And I know these antibiotic durations tend to be ambiguous. I think for most cases you would not need to go the full 10 for uncomplicated disease and someone who's tolerating PO therapy, who you can send home on antibiotics. And I think, you know, when you look at some of these trials which compared antibiotics and no antibiotics, which I know we've alluded to, there's one, the Dynamo trial, which was done just a few years ago, which essentially showed no difference in outcomes in terms of recurrence, need for emergency surgery, et cetera, with antibiotics and no antibiotics when you select the right population. And so I think even knowing that there are cases where this gets better without antibiotics, that also gives me comfort shortening the course to the five to seven day range when I do decide that I think antibiotics are indicated for uncomplicated disease.
- [29:09]
Dr. Meredith Trubitt
Okay, and let's just flip the script for like a quick minute. Let's say complicated diverticulitis that you didn't think that they quite met, like admission criteria. So you're still would. It sounds like the empiric antibiotics are going to be the same regardless because you're still treating the same infectious organisms.
- [29:29]
Dr. Andrew Webster
Yeah, the empiric therapy generally wouldn't change. I would say that if someone was found to have complicated disease on a CT scan, I would advocate for admission in all those cases, just because if they do have an abscess or a perforation or a fistula, there may be other interventions that need to be done to help address those kind of anatomic disruptions purely from a treatment standpoint. Empiric therapies, empiric therapy. We're still covering the same organisms that we're worried about in both cases. I think you can just look at kind of what's the urgency of getting it right initially, I guess. So when you think about patients admitted to the icu, for example, we tend to use very broad empiric therapy up front because they're very sick. So when I think about complicated diverticulitis in patients who are getting admitted for their antibiotic therapy, we do tend to go a little bit broader with IV antibiotic agents. And the way I kind of rationalize that in my own head is that I want to use the drugs that are more likely to cover the bacteria I'm worried about covering, like the enterogram negatives. And the IV agents that we use tend to have more reliable coverage of those bacteria than our oral agents. And so if they're being admitted to undergo further workup or consider some of these other studies, I'll usually place those patients on IV antibiotics.
- [30:57]
Dr. Moni Amin
And just for the specifics, like what, what IV choices Would you make?
- [31:03]
Dr. Andrew Webster
Yeah, so I think if they're coming in from the community, it's really, again, one of the tenets of empiric antibiotic therapy would be, you know, what are we trying to treat and then what are kind of the special situations. And so if they're coming in from the community without risk factors for more resistant organisms, which would be things like recent broad spectrum antibiotic use or hospitalization, recent surgery, nosocomial onset of the infection, known colonization with drug resistant organisms, if you don't have any of those and they're just coming in from the community, usually I'm gonna reach for ceftriaxone and metronidazole because ceftriaxone is very reliable against synteric gram negatives as long as they're not an extended spectrum beta lactamase producer or ESBL organism. So if they're coming in from the community, I'll do ceftriaxone and metronidazole. I tend to avoid ampicillin sulbactum in these cases just because the E. Coli susceptibilities at Cash, like Southeast antibiogram is like 50 to 60%, which is pretty common across the country. And so I like to use something that's a little bit more reliable for E. Coli in particular, given that that's one of the most common bacteria isolated from intra abdominal infections. So ceftrexone metronidazole would be my preferred regimen. And then, you know, usually don't need pseudomonal coverage. If this were nosocomial, you know, or surgery related, you could consider something like cefepime plus metronidazole or Pip tazo if they're known to have ESBL organisms. So this patient's always in the hospital, always getting antibiotics. They grew an ESBL E. Coli out of a urine culture two weeks ago. That may push me more towards even using something like a carbapenem if I know that they're colonized in their gut with these resistant organisms. Since this is an endogenous infection or an infection that's arising from our own normal microbiota, just knowing kind of the resistance patterns of the individual patient can help guide that as well.
- [33:09]
Dr. Moni Amin
Yeah. So, Andrew, you kind of alluded to getting it right from the start, like for when patients come in. And it kind of leads me to talking to you, Bob, a little bit about a lot of times I feel like when I'm calling surgery, things have not been going right from the start for one reason or another. So what Are some of the common diagnostic mistakes you see on the surgical end and like, red flags that are like, well, maybe this maybe isn't diverticulitis. Like, what are things that you look for when you're evaluating patients?
- [33:41]
Dr. Robert Hollis
Yeah, and I think Andrew hit a lot of the symptoms to look out for. There are some oddballs. I mean, sometimes you can have right lower quadrant pain from an abscess that's in the right lower quadrant. You know, the sigmoid can lay over there. Or you can have, you know, urinary dysuria or urinary frequency from an abscess right on the posterior aspect of the bladder. Or, you know, worst case scenario, you have an abscess draining through a vagina and you got fecal, vaginal drains that we see it all. But the more I think, the more concerning things to me are when I hear about the history and time course, if this is something that's been going over, you know, three weeks, I start, I'm starting thinking, is this really diverticulitis or is something, you know, usually it gets worse much faster and they present sooner. Or have they been having recurring episodes for, you know, three months, you know, or they have any, you know, warning signs, blood in their stool, weight loss. That may warn me and think more. Is there an underlying cancer associated with this, or is there an inflammatory bowel disease associated with this and such that can mimic very similar appearances on ct? Sometimes.
- [34:54]
Dr. Moni Amin
Yeah, we don't. I don't think we plan to talk a little bit about it, but I do remember reading a little bit about that. Some of these symptoms, if it, even if it does end up being diverticulitis, it also kind of dictates potential follow ups for post hospitalization colonoscopy, those kinds of things. And so always good to keep in mind what their initial presentation was when we're sending them off for our transition of care.
- [35:19]
Dr. Robert Hollis
Kind of thinking, yeah, the risk of having colon cancer after initial episode of uncomplicated diverticulitis is pretty low, like 2% or less. But after complicated diverticulitis, I mean, sometimes point up to high as 10%. I usually quote my patients 5% so they don't freak out when I'm telling them. This is why I'm getting a colonoscopy. And I'll be honest, most of the cancers that we've found in recurrent episodes, I can look back at the imaging and see something peculiar going on. You know, like these, like, shelving edges on the edge, you know, on the area of the inflammation A very defined segment and, you know, more pronounced bowel wall thickening as opposed to just the mesenteric stranding.
- [35:58]
Dr. Meredith Trubitt
And then the other thing I was reading in kind of like odd presentations is like the genetic component. And the only reason this stuck out to me was I recently had a case at Cash, like of a very young guy who had had recurrent diverticulitis, as in he was younger than me and I'm not that old. I just want everyone on the recording to know that, but act like I then like started reading and there are like these genetic mutations that can predispose someone, I guess to some of that, but I just didn't know about it. And I wasn't sure if there's anything on the history, physical or anything or even on the imaging that kind of makes you think that.
- [36:38]
Dr. Robert Hollis
Yeah. Dr. Lillian McGuire up at Penn helped run some of the GWAS's colorectal surgeon to identify some of those linkages. I don't think we have enough data yet to do any testing on people, but for predisposition, we see diverticulosis all the time on CT scans. And there are some people, I'm like, how are you not symptomatic? And they're like, I'm fine and they're cold and is this like a Christmas tree? So it's hard to predict, be honest. But if I do get referred somebody for diverticulitis in my clinic, I always make sure that I get their CT scans to confirm their findings.
- [37:16]
Dr. Meredith Trubitt
So so far, like, if we're sticking with the case with that we had, which was really uncomplicated diverticulitis, it sounds like potentially getting him set up with antibiotics because of some of his symptomatology at the beginning sounds like because he's uncomplicated plus minus on, you know, maybe making sure he has age appropriate cancer screening, but may not need it solely for the, like a new colonoscopy for all of this. I guess if we're sticking on the empiric therapies, Andrew, it doesn't sound like there's really going to be step down like antibiotic therapy, is that right?
- [37:53]
Dr. Andrew Webster
Yeah, I think for outpatient treatment you kind of make your determination about what regimen you think is best and then, you know, do the duration like we talked about. I think, you know, for more complicated disease, if someone is admitted and they're getting IV therapy empirically, for example, ceftriaxone and metronidazole, you don't necessarily have to keep them in the hospital for the entirety of their course. You know, you can step down to oral therapy. One of the regimens that we discussed from IV therapy, if they're otherwise improved and kind of met the markers for discharge that you're looking for in terms of, you know, tolerating PO symptoms are controlled. They've gotten a few days of IV antibiotics, You can step them down to some of those oral regimens. Just understanding that the there is, you know, theoretically the possibility that when you go from an IV agent like ceftriaxone to an oral agent like amoxclav, you will lose some of your gram negative coverage just based on resistance profiles and enteric organisms. So it's important to counsel those patients if they are going to transition to an oral therapy to complete those last few days, or however it may be just to monitor for any worsening of symptoms after the transition. The only other time where you can really narrow would be in the case that you were able to get some sort of sample. If there was a patient who had an abscess that was able to be drained, for example, then maybe you could get culture data from there and then more definitively guide the therapy with a little more confidence of your outpatient regimen. But typically you're gonna be left with empiric therapy a lot of the time without culture data.
- [39:36]
Dr. Robert Hollis
Andrew My residents often ask me, should we switch to PO antibio for a day and see if the white count changes? And I usually yell at them and say, you know, if we're on pip tazo, the half life of this drug is going to last a whole nother day. You're not going to see anything until they go home after that. How do you recommend when you're transitioning like that?
- [39:56]
Dr. Andrew Webster
Yeah, I think from a switch to pol in the hospital standpoint, the benefit there to me is more from a tolerability standpoint of the oral drug more so than the effectiveness of the drug for that exact reason. I mean, if you've been getting IV therapy for a few days, it's gonna have a washout period. And even if you immediately switch to something that's not effective, it's gonna take time for that inflammation to recur in that infection to kind of pick up steam to be clinically apparent again. So I usually tell patients, you know, when we switch or when we're stepping down, it may be three or four days before you start to feel bad again. It's usually not gonna be day one or day two. So I think there certainly is some merit in doing an oral. The hospital to make sure that they're tolerating the medication, particularly with GI upset being such a common side effect for a lot of the antibiotic regimens we would use. If these are people whose gut has just been inflamed, who had nausea or vomiting, and you want to make sure can you tolerate this very emetogenic antibiotic before you leave? That's very reasonable, but I wouldn't necessarily use that as proof that the agent I chose is going to continue to work when they leave the hospital.
- [41:12]
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- [42:46]
Dr. Robert Hollis
A lot of people hate the Flagyl, right? That's what drives people crazy when they go home. I've heard that Bid Flagyl has the same bioavailability as Tidbit. What do you recommend for your patients?
- [43:00]
Dr. Andrew Webster
So I will say that I was a late adopter of the BID Metronidazole. But there is, I think, a growing consensus and certainly with a lot of the trainees that I work with, there certainly seems to be movement towards the Bid Metronidazole and there's been enough movement over the past few years where my default now for the Most part is to use BID metronidazole for these infections. There are some situations where I still may prefer TID dosing, but for the majority of cases, including something like this, I think that going to a twice a day metronidazole is very reasonable to limit the pillbird, and particularly when other medications like the Cipro, for example, or the trimethoprim sulfa would also be bid. Drugs just kind of lining up that schedule can be helpful. And so I do think that you can, you can simplify the pill burden and kind of align that schedule safely.
- [43:55]
Dr. R.J. Blackburn
Excuse me as I pick my jaw up off the floor, but I'm the only person on this podcast that didn't know that. That knew you could use metronidazole bid.
- [44:04]
Dr. Meredith Trubitt
No, it's new for me too.
- [44:06]
Dr. Andrew Webster
It's definitely a newer. A newer topic. I will say that if you look at a lot of the guidelines, they haven't been changed to say don't use TID to bid. I will say anecdotally, which again, is an important word in this discussion, that it is being done with more and more frequency. And I have yet to see somebody come in for metronidazole deficiency with their infections with BID dosing. So take that for what it is. It would not be per any guidelines that I've seen. All the guidelines are still going to say Q8 hours, but you may see that anecdotally and in my personal opinion, for a lot of these infections, that's gonna be something that's safe to do, but we'll probably be seeing more of that data. I think it really arose from pharmacokinetic type studies and the clinical data is lagging a little bit behind. But now that we're doing it more in practice for a number of reasons, I think we'll probably start to see that catch up.
- [45:06]
Dr. Meredith Trubitt
Oh, I was just going to say my last question was whether an ID consult was appropriate, but given that Bob just curbsided you on this podcast, I think it was probably appropriate to be consulting id.
- [45:17]
Dr. Robert Hollis
Yeah.
- [45:18]
Dr. Moni Amin
Which is, which is also helpful in. In my segue here where, which is I feel like between order sets and up to date and things, I can like sort of figure out an antibiotic regimen relatively well when I'm treating something like this. And then I can ask you guys to fine tune it on the back end. But one of my blind spots, like as a hospital is I'm just gonna be very open and potentially like opening myself up to, like, insult. I don't know is I do not think about nutrition enough, I think. And that's actually a question for you, Bob, which is like, how do you approach nutrition and patients that are like hospitalized with diverticulitis and potential complications, like, how do you approach it on the front end and then how do you approach it as like it, like how aggressive with advancement? Like, how do you approach that?
- [46:05]
Dr. Robert Hollis
Yeah, little data. So a lot of personal opinion here too, but common practices I've seen in many places. It's for an uncomplicated patient like that was presented here. I treat them sort of like my child with gastroenteritis and put them on some, I call it a spoon diet, anything they can eat with a spoon, a lot of clear liquids, maybe a few broths and things. And they'll do that for a day or two if they're progressing. I'll allow their diet to progress with their, as their pain resolves and similar situation with complicated diverticulitis, depending on how we're treating it, how we're managing it. But I will put on my bowel rest. I mean, probably one of the biggest, biggest things about bio regimens is due to the ileus that they can develop due to the inflammation or infection in the area. And it's just you can feel nauseated and bloated and you know, same like, same thing with gastroenteritis. Right. You just, you don't want much.
- [47:01]
Dr. Moni Amin
And I, I didn't read anything about this, but like any role for any sort of. It seems like generally these progress pretty quickly and so there wouldn't really need to be any consideration for like enteral or TP or IV nutrition, any of that stuff.
- [47:17]
Dr. Robert Hollis
If they're needing that, I'm concerned. I probably should have operated on them. But there are some rare and far between scenarios. But one thing that comes up is like, you know, bowel regimens, like, do you need to avoid fiber? And I mean, I just tell them, you know, you probably not want to go eat a steak and a big salad or a bunch of fibrous high residue foods just to keep it simple. But there's a few people that come in really constipated, have so much inflammation, have a hard time having a bone. I sent them out on a little bit of Miralax, but I don't think there's much evidence to guide that.
- [47:52]
Dr. R.J. Blackburn
Cool.
- [47:53]
Dr. Meredith Trubitt
And then I guess in the same vein, what about pain control and specifically opiate pain control when we're also talking about bowel regimens and things like that? How do you kind of draw that line.
- [48:07]
Dr. Robert Hollis
Yeah, for the uncomplicated patient, you know, they're in the er, they're probably going to get some IVP meds right. When they come in. Right. And then they're, you're filling them out. Can you go home? I usually ask that question, like, how do you feel about going home? Is one judgment call of whether they need to be admitted. If they're still asking for pain meds, that would make me worried and I would want to keep them. Now, once a patient is tolerating food, their white count's normal, abdominal exam's benign, and they're like, doc, I just, I to have just a little bit more payments. I've definitely given a short course, you know, five, ten pills to somebody to be able to get out of the hospital, but very limited. I don't, I don't want them relying on that because that's a marker for worsening disease for me.
- [48:54]
Dr. Moni Amin
All right, I think that that's a really good discussion for our first case. And rj, I think we are ready for case two.
- [49:00]
Dr. R.J. Blackburn
All right, so we have another case from Cash like this is Ms. Abby Session, a 67 year old female with type 2 diabetes with a hemoglobin A1C of 8.4% hypertension and stage 2 chronic kidney disease. She presents with severe left lower quadra abdominal pain. For four days. She's had gradually worsening pain associated with high fevers, chills, profound fatigue and decreased oral intake. She's had some mild nausea, no vomiting, denies any hematochezia. Her vitals are a temperature of 39.2 C, heart rate of 108, blood pressure of 140 over 82, with a respiratory rate of 18 and oxygen saturation of 97%. On room air, she is ill appearing but alert with marked tenderness in the left lower quadrant and mild guarding. No rigidity and no rebound. Her white blood cell count is 17.8 with a creatinine of 1.3 and a lactate of 1.6. Her CT of the abdomen and pelvis with IV contrast demonstrates sigmoid diverticulitis with a 4 centimeter pericolic abscess, some moderate pericolic fat stranding and no free air. So, Bob, we're going to take this one straight to you. How do you decide when an abscess is suitable for say, IR drainage versus surgery? So I guess, I guess I'm really asking when, when to call surgery versus ir. How do you think about that?
- [50:38]
Dr. Robert Hollis
We're going to get the call on this Patient this is. And mainly it's for the long term follow up.
- [50:44]
Sponsor/Ad Reader
Right.
- [50:44]
Dr. Robert Hollis
They want to get established, making sure we're making progression and if things get worse, that we're readily available and I'd much rather know early that they're not progressing then late. 4 centimeter abscess. You know, is it 4 by 0.5 or is it 4 by 4? You know, there's a wide variety of that. You can have, you know, a pelvis, it's like an intramural abscess along the colonic wall that if you put a drain in it, you're surely going to get a cold cutaneous fistula versus like a, you know, just a nice golf ball out to the left side of the colon, an easy shot for ir. And then there's the other tricky abscess disease that can be in the pelvis. And, and what I really don't want IR doing is doing a trans rectal drain into that abscess because then maybe I can develop a new fistula not only from the diverticulum but also down to the rectum. Makes surgery really hard down the road. So in those cases, I mean, I actually put it on the IR concept form. No transrectal unless pre approved by surgery. And. But they can do trans gluteal drains sometimes to reach those hard to reach abscesses disease, especially in, you know, women with big older women with bigger cul de sacs where the fluid may collect. But yes, surgery will be falling.
- [51:56]
Dr. Moni Amin
Did you say there's like an IR consult form where you at your cash lac branch?
- [52:01]
Dr. Robert Hollis
There is. Usually it's accompanied not only in electronic medical record, but also with a phone call specified to the team.
- [52:08]
Dr. Moni Amin
No, I was just curious. It seemed like you guys have like kind of a checklist of like the things that you, you want to know before. So it's kind of a random aside.
- [52:15]
Dr. Meredith Trubitt
Sorry, Moni just turned on her QI hat.
- [52:18]
Dr. Moni Amin
Sorry. You can't help it. We kind of alluded to this, Andrew, in the last case, but with the abscess being there and then plus or minus surgery or IR drainage, how does that affect your planning for the antibiotics?
- [52:36]
Dr. Andrew Webster
Yeah, so like we had mentioned, most of the time this is going to be empiric therapy. And so really the initial antibiotic plan is going to be similar to what we discussed for other complicated disease. So for someone who's coming in to be admitted for IV antibiotics, the presence of an abscess, if they don't have those risk factors for more resistant organisms or nosocomial pathogens, then ceftriaxone plus metronidazole is going to be what I'm reaching for, similar to, you know, cases without the abscess. I think where it may differ is that if we are able to get drainage from the abscess and culture, that that can go a long way in terms of looking at, you know, what bacteria are present in this kind of organized infection, what's their resistance pattern? Does that change our kind of definitive therapy or what we're going to send them home on? You know, can I be a little bit more confident that they're going to get better and not worry so much about the clinical follow up, knowing that their susceptible susceptible to what I'm giving them? So I think the initial antibiotic plan would be similar, but maybe you'll get some clinical data that you can use to fine tune it a little bit more. I think that as far as duration goes, it really depends on what's done with that fluid collection, or rather what can be done. And I think Bob just did a nice job kind of outlining some of the considerations there. I think most listeners have probably heard of the Stop It Trial, which was a trial done by general surgeons about intra abdominal infections with source control, where four days of antibiotic therapy after source control is adequate to treat these infections and a complicated diverticulitis could certainly fall within that. There were cases of complicated diverticulitis in that trial. I think I had some trouble as an ID doctor for some time becoming comfortable agreeing what source control was. I think I tend to like absolutely every bit of fluid or every abnormal imaging finding being completely resolved. But that's actually not what the trial used for source control. What the trial used for source control was that the attending surgeon said there was source control and that there is no further spillage of intra abdominal contents and that there were no additional procedures needed to address it. And so in the Stop it trial, the. The criteria for source control was surgical. It was at the discretion of the surgical attending, which was then confirmed by the lead study author. And so I do lean on my surgery colleagues here that if they go in and they say, hey, we got the abscess, we looked or contained the perforation or we did what we could and it's taken care of. Then I feel comfortable doing short courses about four days after that intervention with therapy and keeping in mind that that by the time those interventions are done, depending on the clinical scenario, they may have already received a few days even before the intervention. And so their total duration May be similar, but I think certainly four to five days after that source control procedure would be adequate. If the abscess is in such a spot where you can't really drain it due to concerns about, for example, fistula creation or is just not accessible or it's too dangerous to do, I would extend the duration from that five to seven that we talked about earlier because now we're relying on antibiotics not only to kind of treat the bacteria leading to inflammation, there's an organized infection that we need to also address and that's going to take a little bit longer. And so you'd look at the overall kind of host status. You know, if they're otherwise pretty healthy and they just have, you know, a smallish undrained abscess, then, you know, Maybe going to 10 days is enough. And if they have any kind of concern for immune compromise or it's sizable abscess, you may need to go out towards 14. And there have been cases at our branch of Cashelock where we've actually had them on for multiple weeks with follow up imaging just because of the concern with the involved structures and the size of the abscess where it was kind of co managed even on the outpatient side between surgery and ID in terms of getting follow up imaging and guiding the therapy. So there's definitely a spectrum. When you have something like an abscess and it can't be drained, the ideal situation would be you're able to drain it. But obviously that's something we rely on our surgery colleagues for.
- [56:51]
Dr. Meredith Trubitt
I have a follow up to that one. So this is probably to Bob, but how much time do you give for that repeat CT scan then to see like in the situations where you can't do any type of drainage or source control intervention? Because I usually think of, of like imaging kind of sometimes being like delayed to the response.
- [57:14]
Dr. Robert Hollis
So I'm just, yeah, if they have an abscess that cannot be drained and say it's less than 3 centimeters, usually 3 centimeters, the cutoff of a drain, not drain, or it's in a position that can't be drained, I don't get a CT scan unless I have clinical demise. They're not getting better, they're not progressing. I mean if they progress and can tolerate food, pain goes away, white count's normal. Get them out of the hospital, I'll see them back in the clinic and maybe get a Repeat CT in 4 weeks if I'm planning a surgical procedure with them.
- [57:45]
Dr. Meredith Trubitt
And if it was like in that greater than 4 or greater than 3 cm. But for whatever reason, like anatomically didn't think it was in a position to drain it. Would you do it more frequently, like two weeks or three days?
- [58:02]
Dr. Robert Hollis
I wouldn't. I just saw one in clinic this past week, had an abscess right on top of the vagina. I think part of it drained out of the vagina and. But she clinically feels great. And I just scanned her at four weeks, abscess is gone. If she called me doing worse, that would have prompted it.
- [58:20]
Dr. Meredith Trubitt
Got it. And so only like if they were in the hospital not getting better and then kind of based on those clinical symptoms with like the colleagues following kind of make a joint decision as to when the next scan would be.
- [58:33]
Dr. Robert Hollis
Otherwise you'll get a scan and you'll see something. You don't know what to do about it because they're getting better. You wouldn't change anything.
- [58:38]
Dr. Meredith Trubitt
Yeah, classic medicine conundrum.
- [58:42]
Dr. Moni Amin
Well, I think part of why you're asking is in some of the guidelines they mention, if they're not better in three to five days, even if it's smaller, that's maybe time to reevaluate. But similar to what you're. It's just more of like a, I think more of a timeframe of like, what should I have in mind? Like, okay, I've done this now for X amount of days and they're still really not better. Like what's that time window I guess is the question. Right?
- [59:05]
Dr. Robert Hollis
That is a very practical question because we see it all the time and maybe they're just smoldering white counts as staying right at 13, 14. Like I just don't feel like eating. You know those people I'll try to drag out at least three days to be able to see something substantial different on my ct. If I can get to five days, that's preferred. Okay, but now the people that are going along and then they start spiking fevers and their white count jumps up five points. Those are me doing a more short term basis looking for more free perforation.
- [59:35]
Dr. Meredith Trubitt
Yeah, I think so. Because the other thing that comes up and part of the reason I'm asking is like, it's very easy to explain to a patient like you have this abscess just like you would on your skin and we're going to drain it. It's very hard when you're like, actually we can't drain it. I just had this on service last week. And the watching and waiting aspect of it and how that can drag out and also potentially influence other Care that they can get. You know, I, I think it's just kind of that delicate line that I see a lot. But yeah, like if it's not safe, it's not safe. And so kind of that risk and benefit, having to navigate that is just part of the job too.
- [60:19]
Dr. Robert Hollis
Yeah. I would tell them we're going to radiate you and we're not going to see anything and we'll miss our chance if we do it too early. So we gotta wait.
- [60:27]
Dr. Meredith Trubitt
And so then like going back to this case where you're thinking like maybe you know, going to be able to do antibiotics and do the follow ups to see that things are getting better. Who do you think about for like elective surgeries and whatnot?
- [60:44]
Dr. Robert Hollis
Yeah, elective surgery for diverticulitis has really become a shared decision making for patients. For uncomplicated diverticulitis we don't count the number of episodes anymore. It's more about the burden upon their life. There used to be this fear that if you had these hospitalizations that then you're more at risk for having the free perforation and needing a Hartman's or in colostomy procedure that's actually untrue. The majority of emergency procedures for diverticulitis according to Hartman's are most often 80, 90% of the time someone the first presentation. And the reason is once you've had multiple attacks, you get scar tissue just like you do anywhere else in your body. Also on your colon. We see it in surgery. And that I think helps prevent from these free perforations, but doesn't necessarily prevent from the morbidity of the disease. Now with complicated diverticulitis like this patient, their chance of recurring episodes of needing hospitalization are certainly higher than uncomplicated. I think most studies are going to say within five years around a quarter to up to 50% of patients may have a repeat episode. But again it may not be as severe. Sometimes it might. I see like three different paths for these patients. I would say one, they get better and then they feel great. It didn't really bother them. We continue to watch them. There's another people who really just have these smoldering symptoms that never get better. We end up having to do surgery and there's certainly the people that have recurrent abscess and have to go back in and get re drained, perhaps keep a drain until they have surgery. But over overall it's always an individualized decision based off of their comorbidities, their lifestyle. You know, are they like a pilot and they don't ever want this to happen while they're in Indonesia. It just depends on the situation.
- [62:33]
Dr. Meredith Trubitt
So everyone like with complicated disease in a way probably warrants like the surgery consult to at least figure out what their outpatient plan is going to be.
- [62:43]
Dr. Robert Hollis
I agree with that and to have follow up and have that discussion. Our guidelines from American Society of Colorectal Surgeons recommend that we consider resection patients who have had a hospitalization for complicated disease. But it's not a definite.
- [62:58]
Dr. Moni Amin
All right, lead us into our last case.
- [63:02]
Dr. R.J. Blackburn
All right, we have one more patient in cash like here. Mr. Perry Foration, 72 year old male. I'm too much with the names tonight. 72 year old male with known coronary artery disease, hypertension and stage three chronic kidney disease. He describes diffuse abdominal pain for 12 hours. It was sudden onset and severe. The pain has been constant and it began in the left lower quadrant and spread diffusely throughout the abdomen. There has been associated nausea but no vomiting. He's reporting chills, dizziness and weakness. Temperature was 38.6 degrees C, heart rate of 118 with a blood pressure of 92 over 54 and a respiratory rate of 24 with oxygen saturations of 96% of room air. He is ill appearing and diaphoretic with a rigid abdomen and diffuse tenderness guarding and he has rebound his hypoactive bowel sounds with a white blood cell count of 20.5, a creatinine of 1.8 and a lactate of 3.4. The CT abdomen pelvis with IV contrast shows sigmoid diverticulitis with with free intraperitoneal air and fluid. So Bob, this is definitely, you're definitely getting a call from me on this one. So what, what imaging findings on CT obviously clinch the diagnosis of perforation for you. And could there be any mimics or anything that. That we might should watch out for.
- [64:37]
Dr. Robert Hollis
With the exam and story that you told me it won't take take much of a CT finding for me to want to operate on this person. They clearly have peritonitis, early signs of sepsis and are not doing well. They're in the sick category and if they got admitted to the hospital that's perhaps they called a sleepy surgeon that went listening because this patient needs to be in the operating room. But to get more into the CT findings you'll see this right? You'll see the possible free perforation, free fluid and sometimes it's just a few specks on the medial side of the colon. And a little bit of layering fluid in the pelvis. Because the body in these episodes, if there is inflammation that leads to a small perforation, has amazing abilities to seal these small holes, like through epiploic or your momentum in your abdomen. And often it will just seal things over very quickly. Other times it can be a lot worse. But there's a spectrum, minute mute spectrum is a small amount of air of the liver, but no free fluid whatsoever. Again, a hole that's sealed quickly. Other CT findings would be diffuse free air, free fluid throughout the abdomen, you know, multiple mesentery abscesses. All those are concerning. So.
- [65:56]
Dr. Meredith Trubitt
So this person taking to the. Or doing your thing for the medicine equivalent of that. Yeah. After that, how do you counsel patients about risk of recurrence? Kind of also, what are you counseling them right before surgery to tell them what to expect? All of those kinds of things?
- [66:17]
Dr. Robert Hollis
Yeah, no, I think that's important because, you know, there's a lot of hospitals that may be, you know, on nights and their surgeon's taking them two hours to get there, and they want to. The patient's really nervous. This is about source control in removing the diseased area. A lot of it depends on the degree of inflammation and spillage for guiding our approach. This patient sounds like they're likely sick. And if they truly have a bunch of air and fluid throughout their abdomen, they're going to get likely an open operation to be able to examine everything. We're going to remove that disease, part of the colon out, and then we have two choices. One is just to bring up part of the colon up to the dominant wall as an end colostomy. There's no connection, no risk in the recovery of anastomotic leak. But more recently, there's been data supporting the safety of us actually reconnecting the colon, but pulling up an ostomy proximally in the small bowel. The benefit of this is that reversing a small bowel loop ileostomy is much easier. And we have a higher probability of reversing ostomies in patients with patients long term, which will provide a lot more equity and care for many different reasons and is better patient satisfaction long term. And then the last situation is when, if things are so bad that we can't say if we remove part of the colon, sometimes we just pull up part of the colon right proximal to all the badness as a loop colostomy just to divert away from that area that's in a really bad bailout situation. All Three of these scenarios do involve an ostomy. Now I'm passionate about ostomies. Everybody's so scared about an ostomy and this change of activities a day living. But there are amazing people who can live, whether they're old or young with an ostomy even for a temporary period of time, which is in this case.
- [68:13]
Dr. Meredith Trubitt
And so then once they have their ostomy after that acute hospitalization, they would just follow up with you to hopefully if they were a candidate for a reversal later to do that.
- [68:27]
Dr. Robert Hollis
And they may bug you about that, right?
- [68:28]
Dr. Meredith Trubitt
Yeah.
- [68:29]
Dr. Robert Hollis
Doc, when do you think the surgeon's gonna reverse this ostomy? You know, maybe you're co managing in the recovery and they're asking that with somebody with a Hartman's procedure where we just brought up the end of the colon up to the skin, often it's a little bit longer cause it's a bigger operation to reverse that ostomy. And sometimes, you know, the shortest interval is three months. More often it's six months because they're sick and they just need to recover. And now the loop ileostomy, if we're able to reconnect things, sometimes it can be just eight weeks. But again depends on the patient's recovery. Sometimes it can be closer to 12 weeks.
- [69:06]
Dr. Moni Amin
Okay, yeah, that's helpful so that I'm not automatically deflecting completely back to you, but I mostly will deflect back to you about that stuff. But a good frame of reference and just to kind of, you know, close out on like kind of a catch all question. Talk to me about seeds and nuts. Is that something I need to be telling them avoid with like the blague or are they okay?
- [69:26]
Dr. Robert Hollis
I tell my patients that if you eat it and you hurt afterwards, don't eat it. But there is no data to support avoiding seeds and nuts. Total, total myth out there. Do you agree, Andrew?
- [69:38]
Dr. Andrew Webster
Yeah, no, I, I think that's words to live by there. If it hurts when you do it, stop doing it. It's why we go to medical school. I love it.
- [69:50]
Dr. Moni Amin
Great. I'm so glad we could end on that kind of note. Well, not quite. I was going to go to each of you so we'll start with Andrew. Since Bob, you've been talking for a minute. Get you a chance to catch your breath a little bit. Andrew, any take up points you have for our listeners at home?
- [70:06]
Dr. Andrew Webster
Yeah, so I think kind of big highlights for me, you know one would be that in, in selected individuals who are immune, competent without signs of sepsis or significant comorbidities with mild uncomplicated diverticulitis. You can monitor some of those select patients off of antibiotics. So diverticulitis does not automatically equal antibiotic therapy. If they are appropriate for antibiotic therapy and they have uncomplicated disease, you should be reaching, you know, one of a few oral regimens that includes coverage against enteric gram negatives and anaerobic bacteria. That's most commonly going to be amoxclav, which is my preference based on side effect profile, but things like ciprofloxacin and metronidazole are also commonly prescribed. Complicated disease should merit admission and administration of IV antibiotics to ensure that they're getting better and to have our surgical colleagues also help assess for what would be the best next step to address some of those anatomical complications and then just finally never hesitate to reach out to id we are people people, so we like to talk to you about your cases and we're always happy to come by and weigh on any of these things if you ever need us.
- [71:24]
Dr. Moni Amin
And always appreciated all right Bob, what are your take home points?
- [71:28]
Dr. Robert Hollis
These complicated diverticulitis cases with abscesses when they're over 3cm in size do consider drainage through interventional radiology and then watch these patients carefully as they progress and make sure to involve your surgical colleagues for follow up. Many of these patients may be considered for electro resections in the future and they certainly warrant follow up colonoscopies to help rule out cancers. And then lastly, if patients present sick, certainly early surgical consultation would be required and I think we gave some realistic pictures of how patients may progress through these surgical scenarios. Awesome.
- [72:09]
Dr. Moni Amin
Thanks guys for such a great discussion.
- [72:15]
Dr. Meredith Trubitt
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [72:20]
Dr. Moni Amin
Yummy.
- [72:21]
Dr. Meredith Trubitt
Still hungry for more?
- [72:22]
Dr. Moni Amin
Yep.
- [72:22]
Dr. Meredith Trubitt
Join our Patreon and get all episodes ad free plus twice monthly bonus episodes at patreon.com curbsiders you can find show notes@the curbsiders.com and see sign up for our mailing list to get our weekly show notes in your inbox including our Curbsiders Digest, recapping the latest practice, changing articles, guidelines and news and internal medicine.
- [72:40]
Dr. Moni Amin
And here at the Curbsiders we're committed to high value practice changing knowledge and to do that we need your feedback so please email us@askcurbsiders gmail.com it also helps a ton when you subscribe, rate and review the show on YouTube, Spotify or Apple Podcasts. A reminder that this and most episodes are available for CME credit for all healthcare professionals through VCU health@curbsiders.vcuhealth.org A special thanks to our writer and producer of this episode, Dr. R.J. blackburn, and to our whole Curbsiders team. Our technical production is done by the team over at Podpaste. Elizabeth Proto does our social media. Jen Watto runs our Patreon. Chris the Chew Manchu moderates our discord. Stuart Brigham composed in theme music. And with all that and until next time, I've been Moni Amin and I am RJ Black.
- [73:24]
Dr. Meredith Trubitt
And as always, I'm still Meredith Trubitt. Thank you and good night.
- [73:46]
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