Joe: what do they say, sounds like a duck, walks like a duck, quacks like a duck,
and the person's had the duck before.
Um, I think you can safely do that
Hello, and welcome to the Evidence Based Urgent Care Urgentology Podcast.
I'm Joe Toscano.
I am on the editorial board of Evidence Based Urgent Care and also the Senior
Research Editor for the sister EB Medicine publication, Emergency Medicine Practice.
Tracey: And I'm Tracy Davidoff.
I'm the editor in chief of Evidence Based Urgent Care.
Joe and I have been involved in urgent care practice and education for many
years, and we're really excited to bring to you This program from EB Medicine, the
evidence based urgentology podcast, our goal for this podcast is to review one of
the recent evidence based urgent care and highlight some of the important things
that have come out of that issue, the learning points and potentially practice
changing information from the piece
Joe: We hope that the podcast will be valuable in and of itself, but it'll
also whet your appetite to delve more deeply into the issue to hone your
practice and even get some CME credit.
Tracey: and, even if you've read the issue already, Joe and I hope
to reinforce the important points and solidify important concepts to
improve your learning as a result.
Joe: If you create an account at ebmedicine.
net, you can subscribe and purchase the issue.
You can check out the interactive clinical pathways they have there.
And you can get up to four hours of CME credit for completing this one issue.
Hey, you've already started your CME journey by listening in.
Tracey: And you can also subscribe for a full year.
So you won't miss anything at the regular price.
That's a great value.
Be on the lookout for occasional promos, sales and special offers
to make it that much easier.
Joe: Hi everyone.
Tracy and I are back.
We're gonna be talking about Diverticular disease this month.
Tracey: Fun.
Joe: Mm-hmm.
Okay, so we've got a couple promos for this month.
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through September 30th, 2025.
It deactivates the following day.
Here's some details.
This sale is a bit different.
It will have two coupon codes in two different offers.
We will be offering two free months for subscriptions.
Then 20% off for courses, LLSAs and any other product.
Coupon codes are quote 2FREE.
That's 2FREE for subscription only offers.
And SAVE20.
That's SAVE 20 for course only promotions and LLSA only promotions.
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There'll also be a webinar on September 17th, 2025 at 11:00 AM Eastern Time.
The title of the webinar is Steroid Stewardship Protect Your Patients and
Your Practice From the Harms of Overuse.
Details of the speakers and presentation titles are available
soon as will be the registration link hopefully in the next week or so.
Tracey: Awesome.
So today we're gonna talk about urgent care management, of diverticular disease.
This was really interesting just for some backstory.
The author is Andrew Alaya, he submitted a proposal for this.
He's from the Netherlands, which I thought was really cool.
Maybe one of our first international authors.
I mean, we use Ivan Coe from England, who does some peer review.
But I thought that was great.
We're now going global.
Woohoo.
Joe: That is awesome.
That he would know and think to do that.
That's cool.
Tracey: Yeah
Joe: That's a great piece too.
Tracey: Yep.
And uh, I know you were gonna say the peer reviewers, but I'm gonna do it.
So the peer reviewers , we had two of them for this, and it was Shelley
Janssen who's kind of new to us.
And then Cesar Jaramillo who's been working with us for some time.
We're actually trying to make this a little more talkative
and a little less reading and a little less, to be frank, boring.
So we're just gonna hit some high points and just have a little
discussion a bit unscripted.
So bear with us and hope y'all find it interesting.
So we've got a couple of take home points , and the first one that I thought
was really interesting really a switch from what we've done for diverticulitis
for years and years is that, hey, antibiotics are not always necessary.
Is that crazy?
So people with mild, uncomplicated diverticulitis, if they don't have
any red flags of like an abscess or like a perforation or somebody who's
really sick with a fever and a lot of pain, they can actually get away
with treatment without antibiotics.
New guidelines, and that's from the American College of Gastroenterology
and I believe the colorectal surgeon folks have supported that as long as
you can really monitor the patient and make sure that they're not getting
any worse you can actually skip the antibiotics and that will really help
reduce overprescribing and resistance.
I've done this once or twice, but I gotta tell you, it's scary not writing
antibiotics for diverticulitis.
I mean, that's been the mainstay for years.
And I find it a little scary.
What about you, Joe?
Joe: Yeah, I've done it one time and as far as I know, it went well.
I didn't necessarily call to follow up with the patient and it was
somebody who actually understood that there was a downside to antibiotics.
I think, you know, when you have your patients who aren't
educated about that, it's harder.
When people understand the downside and that they could get better without
them then it's easier to convince them like a shared decision making thing.
And the, patients should be low risk, they shouldn't be super sick, not be
immunosuppressed, those sorts of things.
But it is, it's so foreign.
I agree.
And, patients should of course know that if they're not getting better or
they're getting worse, they should be seen and get started on antibiotics.
But it is a viable option and it made it into their guidelines, which is awesome.
Tracey: I'm thinking, maybe somebody who's had it before, you know, there's
no question really to the diagnosis.
And they have a primary or a GI person that they can follow up with
and, you just talk to them and you get that gestalt like, this person's
really invested in their care.
They're really reliable.
I can trust them to go home and if they get worse to go to the hospital.
They have an understanding about how this stuff works.
That would be a good person to try this on.
If you're gonna do that, the sad part for us, well, I guess it's the good
part for us is that we don't really get follow up on these patients, so we
don't really know what happens to them once they leave our doors , because
even if they do come back, they'll frequently see a different provider.
So you don't really get any follow up and know what happens.
But, we gotta follow the evidence and, I think this is kinda new ground and
new water to tread on with this so stay tuned on this, but I think we're
probably gonna see more of this, because of the antibiotic stewardship stuff.
Trying to stay away from antibiotics as much as possible.
And, surgeons have also gotten a lot more judicious about antibiotics
and about even imaging and about even taking people to the OR.
So yeah, I think try this out on a very specific group of patients because the
evidence does support it and stay tuned.
We'll probably be hearing more about this
Joe: Let me just say one thing about antibiotics that's kind of interesting.
When you think about it.
We've only had antibiotics for what, like a hundred years?
Tracey: Not even.
Joe: And people have been getting dyverticulitis and other
infections for a lot longer.
And it's not that everybody died who got a UTI or pneumonia or
diverticulitis, and obviously some infections are a lot worse than others.
But some things have the potential to get better without antibiotics.
Our immune system has the ability to fight these things.
We need to be careful.
And if we've been treating things for antibiotics for a long time, if that's
been the standard of care, we can't all of a sudden change without evidence.
But just like you said, if the evidence shows it and the experts
are recommending that we, with careful patient selection could do
it, then it's something to consider.
Tracey: Yep.
What about imaging Joe?
Joe: So imaging, yeah.
You know, CT, particularly contrast enhanced CT, is the gold standard for
diagnosing this, for characterizing it, looking at the extensiveness, ruling
out complications like micro perforation or abscess, that sort of thing.
But, in certain patients, a diagnosis can be made clinically, and similar to
what you said about that patient who's had diverticulitis before, those are
the ones where I will talk to them and say, it's gonna be a little bit of a
hassle to get a CT out of urgent care.
You've had diverticulitis before.
This feels like it to you.
You're tender.
You don't have peritoneal signs.
A low risk patient, particularly one who's had it before, you don't necessarily
need a CT to make the diagnosis.
But certainly anybody who's super sick or who has a worrisome abdominal exam,
those are the patients who are gonna need to be referred for a CT or if you
have the ability to do it out of your urgent care to make sure you get the
imaging done , so that you can basically determine whether they can go home
or need to be in the hospital on IV antibiotics or need further intervention.
I thought that the issue was super cool about talking about
point of care ultrasound.
I mean, I use point of care ultrasound.
I've never used it on a hollow viscus or hollow visci.
But the images in the issue as well as the evidence that they cited showed that
you can visualize uninfected diverticula or infected inflamed diverticula.
So it's kind of cool.
I think we may see more of that.
The issue did also talk about the use of MRI in selected patients.
This would probably be like our pregnant patients, where you were worried that
you really needed to know more either to make the definitive diagnosis,
to rule out a GYN issue, let's say.
I'm not sure if our radiologists are doing this.
I mean, I, honestly I would have to check whether a radiologist
would feel comfortable diagnosing diverticulitis or ruling out a
complication with just ultrasound alone.
So that's where MR comes in, just gives you that big global view of the pelvis.
And this is a diagnosis where there's good sensitivity and specificity with MR.
So it can be used in situations where you need to do imaging,
but CT might be contraindicated.
Pretty much pregnant patients we're talking about.
And, all of this helps us, in addition to our h and p, recognize
these high risk patients.
In urgent care we want to try to take care of our low risk patients in making it not
that complicated, but as quickly as we can, identifying those high risk patients.
Trace, what do you think about that?
Tracey: Yeah, I mean, I think we're all pretty good at that.
Recognizing sick, not sick.
We always say this , you know, go back to your vital signs first, look
for that temperature, that elevated heart rate, that low blood pressure.
If you have any of those that are abnormal, that's gonna increase the risk.
Obviously, you're dealing with somebody that's a little more sicker than
your garden variety, my belly hurts.
And always make sure you do that really good abdominal exam on people like this.
You're looking for tenderness, rebound guarding a sense of mass.
One of my favorites is documenting how they get on and off the exam table.
Somebody that's got peritoneal signs is gonna have some difficulty
getting on and off that exam table.
They're gonna kinda crawl onto it or roll onto it or say, oh seriously,
you want me to get up there?
So you wanna look at that and I always document that too.
If they bounce on and off the exam table, it's a pretty safe bet
they don't have an acute abdomen.
So that's good.
Other high risk things, elderly.
Remember the older you get, the less likely it is that you're going to
have peritoneal signs or guarding or really obvious abdominal pain.
People can have perforations and all sorts of infectious complications
when they're elderly with really minimal findings on exam.
Worry about those diabetics.
Remember, diabetics may have some neuropathy in the abdominal space and may
present very late when they have something very serious going on in their abdomen.
Immunosuppression, same reason.
They may not develop as much as an inflammatory response.
And it may be difficult for you to assess something, so keep a higher
index of suspicion with them.
Inability to tolerate PO.
I mean, Obviously that's something that we're pretty sensitive to, that
if a patient can't tolerate PO they're gonna get dehydrated and we should
probably send them to the ED as well.
And not just high risk when you're seeing them.
I mean, you wanna explain to them what those high risk factors are so
that if you do send them out and don't send them to the emergency room, the
patient themselves will recognize that, Hey, I've now become decompensated,
or I've now increased my risk and it's time for me to get seen again.
If not in the emergency department, at least back in the urgent care for
another serial abdominal exam or with their primary care doctor or their
specialist, whoever it is that they're gonna see . So definitely recognize
those high risk patients, those are the ones that are gonna subsequently end up
in the emergency room , and hopefully you'll catch it and they won't go
home and then have to go back to the emergency room at that point in time.
What other things were kind of interesting about this article that might have been a
little different than what we're used to
Joe: Yeah, I think, diet seems like it's a big part, or at least both
of us trained a while ago and have been kind of indoctrinated by people.
You know, I think this has a bearing on the pathophysiology of diverticulitis
and then maybe also the treatment.
It's interesting.
I mean, I can, exactly like you said, I can remember learning that stuff
like popcorn seeds and nuts, basically high residue fiber, pieces of corn,
stuff that ends up more likely to pass through completely undigested
is very bad for diverticular disease.
It's gonna get into the diverticula, clog them up and cause infection.
And I think a lot of that came from earlier on when the treatment of
diverticulitis was, before we had good antibiotics, basically, a person
would have that portion of their colon resected surgically, and when they
removed it, what would they find?
Well, seeds and nuts and corn and popcorn stuck in the diverticula.
And so, at least the logical inference there was that those
things were causative, but.
Since there's less surgery being done and a lot more colonoscopies,
most gastroenterologists will tell you they go into a colonoscopy
and guess what they see?
Seeds and nuts and popcorn stuck in diverticula and they're
not infected or inflamed.
So it may not be that kind of causal link that we were worried about or educated
about for such a long period of time.
Fiber in general, whether it's high residue or low residue,
so a little bit more digestible fiber, is probably important.
The author cites that there's kind of back and forth research in terms of whether
a high fiber diet decreases attacks of diverticulitis, but it does seem to
alleviate diverticulosis in general and kind of prevent some of the complications.
And that's because it decreases intraluminal pressure.
It kind of keeps stuff passing through the colon and it's a little bit less
likely and it's just a good thing in general anyway, high fiber diet is.
If it were the diet that helped this or something that were unhealthy, I think
it'd be a lot harder to recommend that.
Whether the evidence shows that you're never gonna have diverticulitis
if you eat a high fiber diet, I don't think that's there.
We talked about treating patients without antibiotics when they
have mild diverticular disease and they're not high risk.
But one of the things that is felt to be important for them
is to really kind of cut back.
So give them some relative bowel rest as part of their treatment, whether
they're on some antibiotics or not.
So that would be like clear liquids for a couple of days, and then
easing back into a fiber rich diet as they start to feel better.
So those are kind of the important dietary things to keep in mind.
And this kind of leads into another concept that I think
you're gonna talk about.
What's going into our mouth and how it affects our microbiome and,
fiber, not only as a bulk agent, but also some forms of fiber or
prebiotic can affect our gut flora.
And, again, thinking about pathophysiology and is it really obstructive
mechanical type things that's causing diverticulitis or is it more biological?
Is it microbiome related?
Kind of some interesting stuff there, don't you think?
Tracey: Yeah that was really interesting to me too.
We never really thought much about our microbiome, and now all of a sudden
we're finding all these things that it's becoming extremely important too.
You know, just the antibiotic stewardship alone, you're killing off or changing
your microbiome and the long reaching effects are of that and how many different
things that really affects in your body.
One of the emerging researches is saying that your gut dysbiosis that
can even occur when you're younger from antibiotics when you're younger or from
your dietary habits when you're younger can influence turning out to have
diverticular disease when you're older.
When I trained, I always thought, you know, chronic constipation and
strain on stool is what pop those little diverticula into your colon.
But now the thoughts is that that may contribute somewhat, because of
the lack of a fiber diet, but it may actually have to do with the bacteria
that are living in your intestines.
So, strains of lactobacillus and bifidobacterium specifically are being
studied currently, as an imbalance of those in your colon may predispose you
to be getting diverticulum as you age.
One thing we didn't really mention is age.
It's really weird to see diverticulosis in kids.
I mean, it does happen in diverticulitis, in kids, but it's so rare.
I can honestly say I've never seen it in anybody that's
probably younger than 35 or 40.
So as you age, that constant use of your colon, the constant dietary
changes, the changes with your microbiome predispose you to developing
these diverticulitis over time.
It's kinda like arthritis of your intestines.
Joe: Exactly.
Wear and tear change.
Tracey: Yeah.
'Cause if we went and we scanned everybody who was 25, most people
probably wouldn't have too many diverticulum, but if you went and
scanned everybody who's 85, probably 90% of them would've some diverticulum.
So yeah, age is another thing that obviously is an
increased risk factor for it.
But something more that you want to think about in an older person as a
part of your differential diagnosis rather than a younger person.
You did mention pregnancy , that's another thing.
Diverticulitis can occur in pregnancy.
Again, I don't think I've ever seen it, but definitely something that should
be on your differential diagnosis because there's a lot more challenges
to that of how you diagnose it.
It's not your basic standard, left lower quadrant abdominal pain.
It can be other things because of the way the uterus displaces the colon.
so something that you really kind of have to have on your radar to think about it.
Maybe if somebody had had it before you would think of it, or if it was a what
they're now calling geriatric pregnancies.
You know, if somebody called me a geriatric pregnancy when I was
pregnant, I would've been really mad.
Joe: Slap
Tracey: I know, right?
Yeah, I had my first in my thirties, I think that made
me geriatric, but whatever.
Yeah, so, wrapping back around, we were talking about microbiomes.
So, yeah more to come on this.
You know, I don't think there's any evidence that says we should be giving
everybody bacteria to eat to fix their diverticulitis or diverticulosis
. But, definitely something that's really emerging research and that
we'll probably be seeing more of
Joe: Yep.
Tracey: What else?
Joe: Pain control, right?
This is a pretty painful condition.
One of the main reasons why people seek care is that it hurts.
Well, in addition to kind of making the right diagnosis and identifying
our high risk patients and sending them along, anybody that we're
able to send home, in addition to talking to them about antibiotics, no
antibiotics and the dietary changes, clear liquid diet, that sort of thing,
how are we gonna manage their pain?
Tylenol's kind of the easiest, probably safest thing to recommend.
For many things we see in urgent care, NSAIDs are reasonable
choices, but really not here.
It increases the risk of perforation and bleeding.
These patients have a basically inflamed colonic mucosa.
So the risks go way up with using NSAIDs in these patients.
So we need to keep that in mind.
It can't be sort of a knee jerk, here take ibuprofen, Tylenol, or combination.
We really need to avoid it in really any patient, not just those
other groups of patients that we consider to be NSAID sensitive.
We should really consider all of our diverticulitis patients NSAID sensitive.
I don't think there's tons of evidence about that.
But it's a theoretical concern and something we should keep in mind.
I would say occasionally get that patient who's super uncomfortable, most of
those patients are not gonna go home.
But if they are gonna go home if you are able to do the workup and
determine that there's no complication and they're not a high risk
patient, then they were to go home.
But in more severe pain, that's where you might, might, might consider
opioids, but really short term.
I mean, that's gonna actually complicate things, increase their intraluminal
pressure and it, it might be something you might say, I'm never gonna do, and
if somebody has pain that bad, they're just gonna have to go to the ED to get
it sorted out or have to be admitted.
But I think if they end up getting admitted, they're probably gonna
get IV opioids in that case.
Although, I will say, gosh, in my ED practice, IV
acetaminophen is just incredible.
Tracey: Love that stuff.
Joe: I don't know why it works so much better for any kind of pain than oral, and
I don't know if it's because it all gets in there at the same time or what, but
it's my first choice in a lot of patients.
You know, even moderate pain.
And I'll talk to them and say, look, we're gonna try this first
and let's see if you feel better.
And then we can always give you stronger stuff, but it's
incredible how well that works.
I wish we had something like it in urgent care 'cause it's
safe and, super effective.
But anyway, that's a little bit different than what we're talking about here.
So anyway, the key messages, avoid NSAIDs in diverticular disease.
Tracey: Yeah, I would also say, the narcotics as well if you're sending
the patient home, for a couple reasons.
One, the constipation issue, but also it theoretically could mask symptoms.
Opioids don't alleviate pain completely.
We used to say, don't ever give an opioid to an abdominal
pain you haven't worked up yet.
But I think some of that does ring true because if they're feeling a little
bit better, they may not realize that they're getting a little bit worse
. And that might be something that you're a little bit concerned about.
In my humble opinion if you think that patient is sick enough that they
need narcotics for pain control, you probably should be sending them to
the E D and not sending them home.
And if they're refusing to go to the ED and they want pain medication, then
that's even more of a reason because, you know that person's probably not
gonna do what you say in the first place.
Joe: Focusing wrong priorities.
Yeah.
Tracey: You don't wanna give them more ammunition to avoid
going to the emergency room.
Joe: I mean, I would never do it with a clinical diagnosis.
I think anyone to know that there's no complication and it would basically
facilitate outpatient management only, and it's not a routine thing.
I agree with you a hundred percent.
It complicates any kind of GI pain really.
Tracey: Let's talk about some of the complications here.
What happens if you miss that diverticulitis and
you send that person home?
What kind of horrible things can they end up with that would be a don't miss.
Joe: Well, they could get better, even without antibiotics, right?
Tracey: Yeah, right.
Joe: But if not, if they were to progress, the kind of first
complication that can occur.
I mean, if you don't have somebody who gets overwhelming sepsis and a
physiologic type complication, would be a local complication of microperforation
where that pressure inside the diverticula rises the inflammation
of the wall of the diverticula.
Again, these are actually, in the pathophysiology, these don't have
that muscular layer, so it's a thinner wall structure than the gut itself.
A lot more likely to perforate, especially if it's infected or inflamed.
So the first thing that would happen would be a small, you could even consider
it microscopic, perf or a perf that couldn't be seen with a naked eye.
You get bowel contents going into the adjacent peritoneal space
around the diverticulum, and you get localized inflammation and
really a localized peritonitis.
What we know from situations where that is identified, let's say
on CT, nothing worse than that.
That's usually amenable to antibiotics.
A lot of times when you see that micro perf on CT, most gastroenterologists
that I talk with, and I think most of the evidence, says those
patients need to be in the hospital on IV antibiotics for two reasons.
The IV antibiotics are a lot stronger.
You can give higher doses parenterally with fewer complications, but also really
to observe them for worsening because the next step in that complication
is that that perforation and leakage of bowel contents into the peritoneal
cavity becomes more extensive or occurs in multiple diverticula and
the body's immune system is not able to contain it, you'll get abscess
formation, which is just basically a more extensive process from perforation.
Once those abscesses get to be about four centimeters in diameter.
Most of the time most specialists are gonna want to do something to drain them.
Smaller abscesses, again, amenable, like micro perforation and localized
inflammation, to IV antibiotics, bowel rest, that kind of thing.
But once your abscess gets big enough, it's kind of a surface
area to volume sort of thing.
Antibiotics in our immune system operate on the area.
They only get into the outside of it.
They can't get into the inside.
And based on studies, that four centimeter diameter is enough for
somebody to want to drain that and collapse it, get rid of that volume.
Used to be a surgical thing, but now a lot of times it can be done percutaneously
and interventional radiologists can go through the abdominal wall.
I've actually seen them go through the back in situations where the
abscess was located more posteriorly and then they can insert a drain which
will help that patient get better.
And then, I had mentioned it earlier on about surgery actually entering the
abdomen laparoscopically or open surgery.
Before there were good antibiotics that was the treatment of diverticulitis that
wasn't getting better with bowel rest and whatever antibiotics there were.
Now it's pretty rare.
If a patient fails those other treatments then they're a candidate for surgery.
And there are a couple of other reasons why a surgeon might take a patient
to the operating room earlier on.
Patients who have strictures as a result of their multiple diverticulitis episodes
would be a candidate for removal of that.
And anybody with recurrent diverticulitis, particularly any young person, I think
they recommend surgical resection of that area just because they're more
likely to get it over and over again.
So surgeries used to be a lot more common, still used in those
more complicated situations.
Tracey: Yep.
So if you miss it and they get worse, well most of the time
they'll probably get better.
Um, but the complications of getting worse would be, we were talking
about perforation and abscess , so probably don't wanna miss that.
So if patients, if they've come back to you a couple times, maybe CT
scan, timely fashion of a CT scan.
Obviously if you've got any of those high risk things, you probably
should send them to the ED so they can get their CT same day.
Some people, you're kind of sitting on the fence.
They have some good follow up.
Maybe you send them home on some antibiotics, they should
have a CT scan at some point.
It's okay to do as an outpatient in a day or two.
It doesn't have to be right away.
But if the diagnosis is in question in any way, shape, or form, or if they're
not improving at the speed that you would like then they probably should
have a CT at least as an outpatient.
You know, if you're in an urgent care setting where you're capable of ordering
those things, it might be worth ordering it or contacting their primary care doctor
or telling them to call their primary care doctor or their GI doctor to
get that CT scan in a timely fashion.
For all kinds of abdominal pains, I cannot mention enough
how useful serial exams are.
Just like we do blood pressures multiple times to try and get a good picture
of what's going on, examine the belly multiple times to see what's going on.
So, you tell that patient when they're discharged, things
that you should seek care for.
Worsening pain, fever, signs of abscess or peritonitis,
so your pain's getting worse.
I tell 'em you can't stand up straight.
You can't jump up and down because your belly hurts too much.
You're curled up in a ball in the bed.
You get a new fever, all of these things are bad things.
That means you need a new exam by somebody.
Somebody needs to lay hands on you to make sure you're not getting worse.
Come back, go to the emergency room, have your primary care doctor see you.
The more times people examine that belly to make sure things are getting
better and not worse , is a good thing.
Joe: Mm-hmm.
Tracey: And then, again, we mentioned things like patients who
are elderly, immunocompromised.
If the diagnosis is in question in any way, shape or form, you're not sure
you quite have a handle of what's going on and you're really concerned about
that patient, always err on the side of caution and send that patient forward
to the ED for further evaluation.
Most of the time they'll end up getting a scan but even just having a
second set of eyes or a second person evaluate the patient is not a bad thing.
We didn't talk about lab work , not everybody needs lab work for this.
Most people don't immediately need lab work for this.
But you know, if there's any concern, they're gonna get the lab work in the ED.
We also didn't talk about UAs.
Urinalysis might be a useful thing if you're trying to figure out,
is this diverticulitis or is this some sort of urinary concern?
Pregnancy tests,
Joe: Pregnancy test for sure.
Tracey: Yeah, if the patient's potentially pregnant, but like I
said, I can't remember the last time I saw diverticulitis in
somebody with a childbearing age.
It doesn't occur that often.
But definitely something that you should think about.
Joe: Yeah, I was trying to think about some of the patients through the years
who I've just kind of exclusively taken care of in urgent care with
diverticulitis and there've been enough that it's not something that I can
say that I've never done before.
The author cites, I guess, sensitivity and specificity in the mid sixties
for history and physical alone.
But they don't specifically say whether the patient, if they've
had diverticulitis before.
I think that that is kind of a big factor for me.
I can't say that it's necessarily evidence-based, but you have
somebody you know, what do they say, sounds like a duck, walks like
a duck, quacks like a duck, and the person's had the duck before.
Um, I think you can safely do that because people can have diverticulitis and
have normal labs and their urine may be abnormal and it shouldn't dissuade you.
The main thing is making the decision, do I need imaging to,
number one, make the diagnosis?
Because the patient's never had it before and it's not super clear based
on their h and p or do I need the CT because I'm worried about a complication?
Yeah, this is diverticulitis, I'm pretty sure, and I'm worried
this person has a complication.
So those are maybe the decisions.
And I was thinking if I had to do any test, again, to make sure I could
send somebody home, it would be a pregnancy test to make sure, not
necessarily that they were pregnant with diverticulitis, but that pregnancy
wasn't masquerading some complication.
I think we're lucky.
You had talked about age and people are more likely to have diverticula
as they get older, so it's not necessarily a younger person's disease.
So we're somewhat maybe saved by that in that it doesn't occur that
much during pregnancy or in women of childbearing potential so that it's
not necessarily in the differential as much, but it can still happen.
So you gotta keep it in mind.
Tracey: Right.
So in closing let's just mention, diverticulitis diverticular disease.
They're not gonna walk in there with an arrow pointing to their lower quadrant and
saying, I have diverticulitis right here.
Presentations can be very variable, so you really have to use your detective skills,
getting that good history, that good physical, to figure out what's going on.
Not everybody needs an image.
Not everybody needs antibiotics, but being smart about who does and who
doesn't , is really key to trying and managing these people appropriately.
Really think thoughtfully about it before you make any decisions about
what you're gonna do with the patient.
I always say, go with your gut.
If you think there's something wrong, there's, you know, there's.
Exactly.
There's probably something wrong and there's nothing wrong with having
that person be evaluated in the ED and confirming or negating the
fact that they have diverticulitis.
. Joe: There you go.
Tracey: Any other closing thoughts?
Joe: No, I think we covered it pretty well.
I'm gonna read this issue again because of the microbiome stuff.
I think it's something I'm just becoming more interested in,
in general in terms of health.
It's sort of a naturopath kind of thing, the naturopaths have been focused on
that sort of for a while, but it seems to be more important in some of our
allopathic diseases and understanding it, the classic change in microbiome
with c diff, gosh, you take an antibiotic, it changes your microbiome,
you get this terrible diarrhea, right?
But with the idea that there's more bacteria in our gut than there are
living cells in our body, it's probably gotta be important in a lot of ways that
we are still beginning to understand.
So the fact that the pathophysiology might be based on that and that maybe some
treatments might be that you could take a probiotic or a prebiotic or something and
maybe get better is kind of interesting.
And I look forward to seeing if that gets born out with the research.
Tracey: All right.
Sounds great.
Joe: What are we doing next month?
Do you know yet?
Tracey: I do.
It's yours truly does low back pain.
Joe: Oh, nice.
I get to interrogate you then
Yeah.
Tracey: So you do get to interrogate me.
It's payback s a you know what.
Yeah, one of my favorite topics.
It's a love hate relationship.
Just to share.
I've had horrible back pain my whole life.
Multiple surgeries, whole nine yards.
And I think people don't do back pain justice, you know, they don't treat
it with the respect that it deserves.
And there's also an educational gap as to how to explain to people back pain.
And I know it's really frustrating.
I mean, in the two thousands we're all like, oh, they're
just drug seekers, you know?
And a part of that was our own fault in emergency room, giving
them, pain is the fifth vital sign.
Don't get me started with that.
But yeah, so I think it'll be an interesting article about ruling
out red flags and really going over the evidence with what treatments
work and what treatments don't work.
And I bet you're gonna find a few things that are going to surprise you.
Maybe not you Joe, but maybe our listeners
Joe: I can't wait.
I'm looking forward to it.
Tracey: Me too.
Joe: Thanks listening everybody.
Have a good month and we will talk to you soon.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.
net and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.
net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.