Correspondence

Diverticulitis

N Engl J Med 1995; 333:1785-1786December 28, 1995

Article

To the Editor:

We disagree with some aspects of the studies and therapy of the 70-year-old man with diverticulitis reported by Drs. Nanda and Amini (Aug. 24 issue).1 We question the need for a barium enema, especially one performed on the same day as the computed tomography (CT). CT is the single best test for the diagnosis of diverticular inflammation. In one study,2 it revealed inflammation of pericolic fat 98 percent of the time. CT also reveals unsuspected extraluminal disease, such as an abscess, without the risk of barium peritonitis, which may result from a barium enema.

We also question treatment with both metronidazole and clindamycin. This therapy is redundant — one drug or the other should be used, but not both. We use metronidazole because it is much cheaper and involves less risk of pseudomembranous colitis. In addition, we almost always give a drug that protects against gram-negative organisms.3

Jonathan David, M.D.
Lisa A. Ozick, M.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10037

3 References

1. 1

   Nanda R, Amini J. Diverticulitis. N Engl J Med 1995;333:498-498
   Full Text | Web of Science | Medline

2. 2

   Hulnick DH, Megibow AJ, Balthazar EJ, Naidich DP, Bosniak MA. Computed tomography in the evaluation of diverticulitis. Radiology 1984;152:491-495
   Web of Science | Medline

3. 3

   Ozick LA, Salazar CO, Donelson SS. Pathogenesis, diagnosis, and treatment of diverticular disease of the colon. Gastroenterologist 1994;2:299-310
   Medline

To the Editor:

The images obtained in a patient with diverticulitis are illustrative and elegant. It is important to point out, however, that the routine use of CT in patients with uncomplicated diverticulitis adds cost without clinical benefit. In the case described, plain abdominal radiography, empirical antibiotic therapy, and observation would have sufficed, with CT reserved for patients with clinical deterioration or a poor response to treatment. Sigmoidoscopy and barium enema are warranted to rule out cancer and confirm the diagnosis of diverticulitis. The proliferation of readily obtainable, noninvasive tests has contributed greatly to the increasing cost of medical care, often with no proof that patients' outcomes are improved.

William Harford, M.D.
Walter L. Peterson, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75235

To the Editor:

Nanda and Amini report using a low-pressure barium enema in a patient with clinical evidence of acute diverticulitis. In such situations, the use of barium is contraindicated. If a perforation is present or if one is created by the instillation of barium, barium peritonitis may result. If there is concern about the diagnosis of acute diverticulitis, a water-soluble material (e.g., Gastrografin, Squibb) should be used. Wexner and Dailey1 reported that the early use of an enema containing such material is the most cost-effective means of establishing the diagnosis.

Virendra A. Parikh, M.D
Parkview Memorial Hospital, Fort Wayne, IN 46805

1 References

1. 1

   Wexner SD, Dailey TH. The initial management of left lower quadrant peritonitis. Dis Colon Rectum 1986;29:635-638
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: These letters raise important issues in the management of diverticulitis. We agree that CT should be the first test performed if diverticulitis is suspected. If a barium enema is considered, it should be performed by an experienced radiologist under controlled conditions, with a low volume of contrast material at low pressure, and provided there is no contraindication, such as peritonitis or suspected perforation. The radiologist should be asked to limit the study to the colonic segment in question. If there is evidence of severe disease, perforation, or systemic symptoms, treatment with antibiotics should include those that affect gram-negative organisms.

The role of CT as compared with barium enema remains controversial in the diagnosis of diverticulitis.1,2 Some authors suggest that CT yields a high rate of false negative results and should be reserved for patients whose conditions do not respond to medical treatment or in whom the diagnosis is uncertain.3 Barium enemas are safe and underused.1,4 In a study of 102 patients with acute diverticulitis who had barium enemas, there were no complications.4 Thus, earlier studies do not substantiate the traditionally perceived concern about complications of such enemas.1,4

Regarding the type of contrast material used, we believe that contrast enemas can be performed safely with either barium or water-soluble contrast material.4 Such studies are not indicated if there is any suspicion of a perforation or leak in the colon. In treating our patient, we thought that barium enema would complement the findings of CT, because the diagnosis was in doubt. We believe that the selection of the test really depends on experience, expertise, and availability.

We agree that the second antibiotic (clindamycin) did not particularly add to the spectrum of treatment. On the basis of the CT scan, at the time of drug administration we felt more comfortable providing additional protection against anaerobic microbes. Clindamycin covers some additional gram-positive organisms. In hindsight, we agree that this clinical decision was an empirical one.

Jafar Amini, M.D.
Rakesh Nanda, M.D.
Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth, KS 66048

4 References

1. 1

   Naitove A, Smith RE. Diverticular disease of the colon. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal diseases: pathophysiology, diagnosis, management. 5th ed. Vol. 2. Philadelphia: W.B. Saunders, 1993:1347-63.
   

2. 2

   Case 16: diverticulitis: In: Stephen DH, ed. Gastrointestinal disease (fourth series) test and syllabus. Reston, Va.: American College of Radiology, 1990:252-64.
   

3. 3

   Schoetz DJ Jr. Uncomplicated diverticulitis: indications for surgery and surgical management. Surg Clin North Am 1993;73:965-974
   Web of Science | Medline

4. 4

   Johnson CD, Baker ME, Rice RP, Silverman P, Thompson WM. Diagnosis of acute colonic diverticulitis: comparison of barium enema and CT. AJR Am J Roentgenol 1987;148:541-546
   Web of Science | Medline