1 00:00:00,049 --> 00:00:03,745 Joe: what do they say, sounds like a duck, walks like a duck, quacks like a duck, 2 00:00:03,775 --> 00:00:05,485 and the person's had the duck before. 3 00:00:06,758 --> 00:00:09,998 Um, I think you can safely do that 4 00:00:18,136 --> 00:00:21,166 Hello, and welcome to the Evidence Based Urgent Care Urgentology Podcast. 5 00:00:22,131 --> 00:00:23,131 I'm Joe Toscano. 6 00:00:23,330 --> 00:00:27,920 I am on the editorial board of Evidence Based Urgent Care and also the Senior 7 00:00:27,930 --> 00:00:31,980 Research Editor for the sister EB Medicine publication, Emergency Medicine Practice. 8 00:00:32,633 --> 00:00:33,933 Tracey: And I'm Tracy Davidoff. 9 00:00:33,943 --> 00:00:36,873 I'm the editor in chief of Evidence Based Urgent Care. 10 00:00:37,002 --> 00:00:39,762 Joe and I have been involved in urgent care practice and education for many 11 00:00:39,762 --> 00:00:43,719 years, and we're really excited to bring to you This program from EB Medicine, the 12 00:00:43,729 --> 00:00:48,349 evidence based urgentology podcast, our goal for this podcast is to review one of 13 00:00:48,349 --> 00:00:52,382 the recent evidence based urgent care and highlight some of the important things 14 00:00:52,382 --> 00:00:55,462 that have come out of that issue, the learning points and potentially practice 15 00:00:55,462 --> 00:00:57,026 changing information from the piece 16 00:00:57,377 --> 00:01:00,287 Joe: We hope that the podcast will be valuable in and of itself, but it'll 17 00:01:00,297 --> 00:01:04,057 also whet your appetite to delve more deeply into the issue to hone your 18 00:01:04,057 --> 00:01:05,697 practice and even get some CME credit. 19 00:01:05,697 --> 00:01:07,867 Tracey: and, even if you've read the issue already, Joe and I hope 20 00:01:07,867 --> 00:01:11,157 to reinforce the important points and solidify important concepts to 21 00:01:11,157 --> 00:01:12,647 improve your learning as a result. 22 00:01:12,916 --> 00:01:14,446 Joe: If you create an account at ebmedicine. 23 00:01:15,056 --> 00:01:17,327 net, you can subscribe and purchase the issue. 24 00:01:17,797 --> 00:01:20,497 You can check out the interactive clinical pathways they have there. 25 00:01:20,897 --> 00:01:24,337 And you can get up to four hours of CME credit for completing this one issue. 26 00:01:24,927 --> 00:01:27,367 Hey, you've already started your CME journey by listening in. 27 00:01:27,772 --> 00:01:29,552 Tracey: And you can also subscribe for a full year. 28 00:01:29,552 --> 00:01:31,789 So you won't miss anything at the regular price. 29 00:01:31,789 --> 00:01:32,799 That's a great value. 30 00:01:32,906 --> 00:01:35,886 Be on the lookout for occasional promos, sales and special offers 31 00:01:35,886 --> 00:01:37,216 to make it that much easier. 32 00:01:37,840 --> 00:01:38,710 Joe: Hi everyone. 33 00:01:39,006 --> 00:01:39,876 Tracy and I are back. 34 00:01:39,876 --> 00:01:42,846 We're gonna be talking about Diverticular disease this month. 35 00:01:43,234 --> 00:01:43,684 Tracey: Fun. 36 00:01:44,133 --> 00:01:44,343 Joe: Mm-hmm. 37 00:01:44,862 --> 00:01:47,322 Okay, so we've got a couple promos for this month. 38 00:01:47,892 --> 00:01:51,842 The back to school sale starts September 12th, and will run 39 00:01:51,842 --> 00:01:53,582 through September 30th, 2025. 40 00:01:53,582 --> 00:01:55,052 It deactivates the following day. 41 00:01:55,366 --> 00:01:56,326 Here's some details. 42 00:01:56,496 --> 00:01:57,786 This sale is a bit different. 43 00:01:57,979 --> 00:02:00,589 It will have two coupon codes in two different offers. 44 00:02:00,762 --> 00:02:03,702 We will be offering two free months for subscriptions. 45 00:02:04,077 --> 00:02:08,097 Then 20% off for courses, LLSAs and any other product. 46 00:02:08,471 --> 00:02:11,547 Coupon codes are quote 2FREE. 47 00:02:11,567 --> 00:02:15,437 That's 2FREE for subscription only offers. 48 00:02:15,727 --> 00:02:17,057 And SAVE20. 49 00:02:17,077 --> 00:02:23,347 That's SAVE 20 for course only promotions and LLSA only promotions. 50 00:02:23,531 --> 00:02:26,621 Just go to the website and you will have all of the details. 51 00:02:27,117 --> 00:02:32,697 There'll also be a webinar on September 17th, 2025 at 11:00 AM Eastern Time. 52 00:02:32,921 --> 00:02:36,131 The title of the webinar is Steroid Stewardship Protect Your Patients and 53 00:02:36,131 --> 00:02:38,051 Your Practice From the Harms of Overuse. 54 00:02:38,221 --> 00:02:41,131 Details of the speakers and presentation titles are available 55 00:02:41,131 --> 00:02:45,107 soon as will be the registration link hopefully in the next week or so. 56 00:02:45,490 --> 00:02:45,980 Tracey: Awesome. 57 00:02:46,350 --> 00:02:49,920 So today we're gonna talk about urgent care management, of diverticular disease. 58 00:02:50,010 --> 00:02:52,710 This was really interesting just for some backstory. 59 00:02:52,990 --> 00:02:56,360 The author is Andrew Alaya, he submitted a proposal for this. 60 00:02:56,360 --> 00:02:59,030 He's from the Netherlands, which I thought was really cool. 61 00:02:59,030 --> 00:03:01,965 Maybe one of our first international authors. 62 00:03:02,025 --> 00:03:05,128 I mean, we use Ivan Coe from England, who does some peer review. 63 00:03:05,528 --> 00:03:06,615 But I thought that was great. 64 00:03:06,675 --> 00:03:07,665 We're now going global. 65 00:03:07,665 --> 00:03:08,265 Woohoo. 66 00:03:08,760 --> 00:03:09,480 Joe: That is awesome. 67 00:03:09,494 --> 00:03:10,890 That he would know and think to do that. 68 00:03:10,890 --> 00:03:11,340 That's cool. 69 00:03:11,745 --> 00:03:12,135 Tracey: Yeah 70 00:03:12,330 --> 00:03:12,960 Joe: That's a great piece too. 71 00:03:13,774 --> 00:03:13,994 Tracey: Yep. 72 00:03:13,999 --> 00:03:16,517 And uh, I know you were gonna say the peer reviewers, but I'm gonna do it. 73 00:03:16,644 --> 00:03:19,279 So the peer reviewers , we had two of them for this, and it was Shelley 74 00:03:19,299 --> 00:03:20,785 Janssen who's kind of new to us. 75 00:03:21,085 --> 00:03:24,509 And then Cesar Jaramillo who's been working with us for some time. 76 00:03:24,849 --> 00:03:27,489 We're actually trying to make this a little more talkative 77 00:03:27,729 --> 00:03:31,709 and a little less reading and a little less, to be frank, boring. 78 00:03:32,079 --> 00:03:34,809 So we're just gonna hit some high points and just have a little 79 00:03:34,809 --> 00:03:36,279 discussion a bit unscripted. 80 00:03:36,279 --> 00:03:38,529 So bear with us and hope y'all find it interesting. 81 00:03:39,229 --> 00:03:42,389 So we've got a couple of take home points , and the first one that I thought 82 00:03:42,389 --> 00:03:46,219 was really interesting really a switch from what we've done for diverticulitis 83 00:03:46,249 --> 00:03:50,419 for years and years is that, hey, antibiotics are not always necessary. 84 00:03:50,869 --> 00:03:51,619 Is that crazy? 85 00:03:51,899 --> 00:03:55,349 So people with mild, uncomplicated diverticulitis, if they don't have 86 00:03:55,349 --> 00:04:00,179 any red flags of like an abscess or like a perforation or somebody who's 87 00:04:00,539 --> 00:04:03,719 really sick with a fever and a lot of pain, they can actually get away 88 00:04:03,719 --> 00:04:05,819 with treatment without antibiotics. 89 00:04:06,039 --> 00:04:09,454 New guidelines, and that's from the American College of Gastroenterology 90 00:04:09,454 --> 00:04:13,694 and I believe the colorectal surgeon folks have supported that as long as 91 00:04:13,694 --> 00:04:16,394 you can really monitor the patient and make sure that they're not getting 92 00:04:16,477 --> 00:04:19,997 any worse you can actually skip the antibiotics and that will really help 93 00:04:19,997 --> 00:04:22,537 reduce overprescribing and resistance. 94 00:04:22,867 --> 00:04:25,851 I've done this once or twice, but I gotta tell you, it's scary not writing 95 00:04:25,851 --> 00:04:27,613 antibiotics for diverticulitis. 96 00:04:27,613 --> 00:04:29,533 I mean, that's been the mainstay for years. 97 00:04:30,013 --> 00:04:31,293 And I find it a little scary. 98 00:04:31,323 --> 00:04:32,093 What about you, Joe? 99 00:04:32,793 --> 00:04:35,613 Joe: Yeah, I've done it one time and as far as I know, it went well. 100 00:04:35,613 --> 00:04:38,563 I didn't necessarily call to follow up with the patient and it was 101 00:04:38,563 --> 00:04:41,753 somebody who actually understood that there was a downside to antibiotics. 102 00:04:41,753 --> 00:04:43,833 I think, you know, when you have your patients who aren't 103 00:04:43,953 --> 00:04:46,089 educated about that, it's harder. 104 00:04:46,316 --> 00:04:49,136 When people understand the downside and that they could get better without 105 00:04:49,136 --> 00:04:52,776 them then it's easier to convince them like a shared decision making thing. 106 00:04:52,776 --> 00:04:55,896 And the, patients should be low risk, they shouldn't be super sick, not be 107 00:04:55,896 --> 00:04:57,426 immunosuppressed, those sorts of things. 108 00:04:57,756 --> 00:04:59,286 But it is, it's so foreign. 109 00:04:59,286 --> 00:04:59,886 I agree. 110 00:04:59,966 --> 00:05:02,853 And, patients should of course know that if they're not getting better or 111 00:05:02,853 --> 00:05:05,073 they're getting worse, they should be seen and get started on antibiotics. 112 00:05:05,073 --> 00:05:07,871 But it is a viable option and it made it into their guidelines, which is awesome. 113 00:05:08,571 --> 00:05:11,112 Tracey: I'm thinking, maybe somebody who's had it before, you know, there's 114 00:05:11,112 --> 00:05:13,662 no question really to the diagnosis. 115 00:05:13,998 --> 00:05:17,598 And they have a primary or a GI person that they can follow up with 116 00:05:17,598 --> 00:05:20,292 and, you just talk to them and you get that gestalt like, this person's 117 00:05:20,292 --> 00:05:21,785 really invested in their care. 118 00:05:22,125 --> 00:05:23,235 They're really reliable. 119 00:05:23,235 --> 00:05:26,715 I can trust them to go home and if they get worse to go to the hospital. 120 00:05:26,715 --> 00:05:29,485 They have an understanding about how this stuff works. 121 00:05:29,955 --> 00:05:31,725 That would be a good person to try this on. 122 00:05:31,775 --> 00:05:35,285 If you're gonna do that, the sad part for us, well, I guess it's the good 123 00:05:35,285 --> 00:05:38,469 part for us is that we don't really get follow up on these patients, so we 124 00:05:38,469 --> 00:05:41,203 don't really know what happens to them once they leave our doors , because 125 00:05:41,285 --> 00:05:43,835 even if they do come back, they'll frequently see a different provider. 126 00:05:43,835 --> 00:05:46,235 So you don't really get any follow up and know what happens. 127 00:05:46,585 --> 00:05:50,219 But, we gotta follow the evidence and, I think this is kinda new ground and 128 00:05:50,275 --> 00:05:53,932 new water to tread on with this so stay tuned on this, but I think we're 129 00:05:53,932 --> 00:05:57,242 probably gonna see more of this, because of the antibiotic stewardship stuff. 130 00:05:57,288 --> 00:06:00,171 Trying to stay away from antibiotics as much as possible. 131 00:06:00,601 --> 00:06:04,376 And, surgeons have also gotten a lot more judicious about antibiotics 132 00:06:04,376 --> 00:06:06,783 and about even imaging and about even taking people to the OR. 133 00:06:07,143 --> 00:06:11,067 So yeah, I think try this out on a very specific group of patients because the 134 00:06:11,067 --> 00:06:12,980 evidence does support it and stay tuned. 135 00:06:13,030 --> 00:06:14,530 We'll probably be hearing more about this 136 00:06:14,890 --> 00:06:18,158 Joe: Let me just say one thing about antibiotics that's kind of interesting. 137 00:06:18,188 --> 00:06:18,878 When you think about it. 138 00:06:18,878 --> 00:06:21,848 We've only had antibiotics for what, like a hundred years? 139 00:06:21,864 --> 00:06:22,204 Tracey: Not even. 140 00:06:22,328 --> 00:06:24,258 Joe: And people have been getting dyverticulitis and other 141 00:06:24,278 --> 00:06:25,598 infections for a lot longer. 142 00:06:25,988 --> 00:06:30,038 And it's not that everybody died who got a UTI or pneumonia or 143 00:06:30,038 --> 00:06:32,858 diverticulitis, and obviously some infections are a lot worse than others. 144 00:06:33,068 --> 00:06:36,158 But some things have the potential to get better without antibiotics. 145 00:06:36,158 --> 00:06:38,798 Our immune system has the ability to fight these things. 146 00:06:38,798 --> 00:06:39,788 We need to be careful. 147 00:06:40,113 --> 00:06:42,783 And if we've been treating things for antibiotics for a long time, if that's 148 00:06:42,783 --> 00:06:45,363 been the standard of care, we can't all of a sudden change without evidence. 149 00:06:45,363 --> 00:06:48,183 But just like you said, if the evidence shows it and the experts 150 00:06:48,183 --> 00:06:50,697 are recommending that we, with careful patient selection could do 151 00:06:50,697 --> 00:06:51,863 it, then it's something to consider. 152 00:06:52,543 --> 00:06:52,697 Tracey: Yep. 153 00:06:53,107 --> 00:06:54,067 What about imaging Joe? 154 00:06:54,437 --> 00:06:55,247 Joe: So imaging, yeah. 155 00:06:55,247 --> 00:06:59,060 You know, CT, particularly contrast enhanced CT, is the gold standard for 156 00:06:59,060 --> 00:07:03,110 diagnosing this, for characterizing it, looking at the extensiveness, ruling 157 00:07:03,110 --> 00:07:06,507 out complications like micro perforation or abscess, that sort of thing. 158 00:07:06,847 --> 00:07:10,867 But, in certain patients, a diagnosis can be made clinically, and similar to 159 00:07:10,867 --> 00:07:14,657 what you said about that patient who's had diverticulitis before, those are 160 00:07:14,657 --> 00:07:17,987 the ones where I will talk to them and say, it's gonna be a little bit of a 161 00:07:17,987 --> 00:07:20,147 hassle to get a CT out of urgent care. 162 00:07:20,147 --> 00:07:22,069 You've had diverticulitis before. 163 00:07:22,339 --> 00:07:23,419 This feels like it to you. 164 00:07:23,419 --> 00:07:24,169 You're tender. 165 00:07:24,169 --> 00:07:25,399 You don't have peritoneal signs. 166 00:07:25,399 --> 00:07:29,179 A low risk patient, particularly one who's had it before, you don't necessarily 167 00:07:29,179 --> 00:07:31,279 need a CT to make the diagnosis. 168 00:07:31,609 --> 00:07:35,859 But certainly anybody who's super sick or who has a worrisome abdominal exam, 169 00:07:36,159 --> 00:07:39,714 those are the patients who are gonna need to be referred for a CT or if you 170 00:07:39,714 --> 00:07:42,802 have the ability to do it out of your urgent care to make sure you get the 171 00:07:42,802 --> 00:07:47,042 imaging done , so that you can basically determine whether they can go home 172 00:07:47,042 --> 00:07:50,222 or need to be in the hospital on IV antibiotics or need further intervention. 173 00:07:50,492 --> 00:07:53,709 I thought that the issue was super cool about talking about 174 00:07:53,739 --> 00:07:54,849 point of care ultrasound. 175 00:07:55,329 --> 00:07:56,886 I mean, I use point of care ultrasound. 176 00:07:56,886 --> 00:08:01,229 I've never used it on a hollow viscus or hollow visci. 177 00:08:01,229 --> 00:08:04,929 But the images in the issue as well as the evidence that they cited showed that 178 00:08:04,929 --> 00:08:09,531 you can visualize uninfected diverticula or infected inflamed diverticula. 179 00:08:09,961 --> 00:08:10,891 So it's kind of cool. 180 00:08:10,891 --> 00:08:13,041 I think we may see more of that. 181 00:08:14,141 --> 00:08:18,821 The issue did also talk about the use of MRI in selected patients. 182 00:08:18,821 --> 00:08:22,181 This would probably be like our pregnant patients, where you were worried that 183 00:08:22,241 --> 00:08:25,661 you really needed to know more either to make the definitive diagnosis, 184 00:08:25,661 --> 00:08:28,491 to rule out a GYN issue, let's say. 185 00:08:28,741 --> 00:08:31,532 I'm not sure if our radiologists are doing this. 186 00:08:31,711 --> 00:08:34,427 I mean, I, honestly I would have to check whether a radiologist 187 00:08:34,427 --> 00:08:39,757 would feel comfortable diagnosing diverticulitis or ruling out a 188 00:08:39,757 --> 00:08:41,227 complication with just ultrasound alone. 189 00:08:41,227 --> 00:08:44,707 So that's where MR comes in, just gives you that big global view of the pelvis. 190 00:08:45,007 --> 00:08:48,884 And this is a diagnosis where there's good sensitivity and specificity with MR. 191 00:08:48,884 --> 00:08:51,854 So it can be used in situations where you need to do imaging, 192 00:08:51,854 --> 00:08:54,114 but CT might be contraindicated. 193 00:08:54,744 --> 00:08:56,589 Pretty much pregnant patients we're talking about. 194 00:08:56,724 --> 00:09:00,064 And, all of this helps us, in addition to our h and p, recognize 195 00:09:00,064 --> 00:09:01,031 these high risk patients. 196 00:09:01,081 --> 00:09:04,625 In urgent care we want to try to take care of our low risk patients in making it not 197 00:09:04,625 --> 00:09:07,985 that complicated, but as quickly as we can, identifying those high risk patients. 198 00:09:07,985 --> 00:09:08,800 Trace, what do you think about that? 199 00:09:09,410 --> 00:09:11,120 Tracey: Yeah, I mean, I think we're all pretty good at that. 200 00:09:11,120 --> 00:09:12,390 Recognizing sick, not sick. 201 00:09:12,440 --> 00:09:15,274 We always say this , you know, go back to your vital signs first, look 202 00:09:15,274 --> 00:09:18,994 for that temperature, that elevated heart rate, that low blood pressure. 203 00:09:18,994 --> 00:09:22,624 If you have any of those that are abnormal, that's gonna increase the risk. 204 00:09:22,624 --> 00:09:24,814 Obviously, you're dealing with somebody that's a little more sicker than 205 00:09:24,814 --> 00:09:26,344 your garden variety, my belly hurts. 206 00:09:26,864 --> 00:09:31,369 And always make sure you do that really good abdominal exam on people like this. 207 00:09:31,369 --> 00:09:34,959 You're looking for tenderness, rebound guarding a sense of mass. 208 00:09:35,409 --> 00:09:39,069 One of my favorites is documenting how they get on and off the exam table. 209 00:09:39,349 --> 00:09:42,359 Somebody that's got peritoneal signs is gonna have some difficulty 210 00:09:42,359 --> 00:09:43,703 getting on and off that exam table. 211 00:09:43,803 --> 00:09:47,288 They're gonna kinda crawl onto it or roll onto it or say, oh seriously, 212 00:09:47,288 --> 00:09:48,153 you want me to get up there? 213 00:09:48,153 --> 00:09:50,815 So you wanna look at that and I always document that too. 214 00:09:50,815 --> 00:09:53,447 If they bounce on and off the exam table, it's a pretty safe bet 215 00:09:53,477 --> 00:09:54,808 they don't have an acute abdomen. 216 00:09:55,258 --> 00:09:55,978 So that's good. 217 00:09:56,258 --> 00:09:58,321 Other high risk things, elderly. 218 00:09:58,321 --> 00:10:05,331 Remember the older you get, the less likely it is that you're going to 219 00:10:05,331 --> 00:10:07,472 have peritoneal signs or guarding or really obvious abdominal pain. 220 00:10:07,472 --> 00:10:09,661 People can have perforations and all sorts of infectious complications 221 00:10:10,031 --> 00:10:13,521 when they're elderly with really minimal findings on exam. 222 00:10:13,861 --> 00:10:15,181 Worry about those diabetics. 223 00:10:15,181 --> 00:10:18,815 Remember, diabetics may have some neuropathy in the abdominal space and may 224 00:10:18,815 --> 00:10:22,209 present very late when they have something very serious going on in their abdomen. 225 00:10:22,519 --> 00:10:24,049 Immunosuppression, same reason. 226 00:10:24,049 --> 00:10:26,769 They may not develop as much as an inflammatory response. 227 00:10:27,119 --> 00:10:30,179 And it may be difficult for you to assess something, so keep a higher 228 00:10:30,179 --> 00:10:31,649 index of suspicion with them. 229 00:10:32,196 --> 00:10:33,726 Inability to tolerate PO. 230 00:10:33,726 --> 00:10:36,875 I mean, Obviously that's something that we're pretty sensitive to, that 231 00:10:36,875 --> 00:10:40,083 if a patient can't tolerate PO they're gonna get dehydrated and we should 232 00:10:40,083 --> 00:10:41,823 probably send them to the ED as well. 233 00:10:42,260 --> 00:10:44,540 And not just high risk when you're seeing them. 234 00:10:44,540 --> 00:10:47,240 I mean, you wanna explain to them what those high risk factors are so 235 00:10:47,240 --> 00:10:49,896 that if you do send them out and don't send them to the emergency room, the 236 00:10:49,896 --> 00:10:54,283 patient themselves will recognize that, Hey, I've now become decompensated, 237 00:10:54,283 --> 00:10:57,954 or I've now increased my risk and it's time for me to get seen again. 238 00:10:58,414 --> 00:11:01,256 If not in the emergency department, at least back in the urgent care for 239 00:11:01,256 --> 00:11:04,589 another serial abdominal exam or with their primary care doctor or their 240 00:11:04,589 --> 00:11:08,083 specialist, whoever it is that they're gonna see . So definitely recognize 241 00:11:08,083 --> 00:11:11,773 those high risk patients, those are the ones that are gonna subsequently end up 242 00:11:11,773 --> 00:11:15,003 in the emergency room , and hopefully you'll catch it and they won't go 243 00:11:15,003 --> 00:11:17,888 home and then have to go back to the emergency room at that point in time. 244 00:11:18,588 --> 00:11:21,782 What other things were kind of interesting about this article that might have been a 245 00:11:21,782 --> 00:11:23,262 little different than what we're used to 246 00:11:24,508 --> 00:11:27,418 Joe: Yeah, I think, diet seems like it's a big part, or at least both 247 00:11:27,418 --> 00:11:31,638 of us trained a while ago and have been kind of indoctrinated by people. 248 00:11:32,083 --> 00:11:36,883 You know, I think this has a bearing on the pathophysiology of diverticulitis 249 00:11:36,883 --> 00:11:38,113 and then maybe also the treatment. 250 00:11:38,426 --> 00:11:39,056 It's interesting. 251 00:11:39,056 --> 00:11:42,916 I mean, I can, exactly like you said, I can remember learning that stuff 252 00:11:42,916 --> 00:11:48,496 like popcorn seeds and nuts, basically high residue fiber, pieces of corn, 253 00:11:48,496 --> 00:11:52,426 stuff that ends up more likely to pass through completely undigested 254 00:11:52,666 --> 00:11:54,586 is very bad for diverticular disease. 255 00:11:54,586 --> 00:11:58,816 It's gonna get into the diverticula, clog them up and cause infection. 256 00:11:59,206 --> 00:12:03,980 And I think a lot of that came from earlier on when the treatment of 257 00:12:03,980 --> 00:12:07,566 diverticulitis was, before we had good antibiotics, basically, a person 258 00:12:07,566 --> 00:12:11,106 would have that portion of their colon resected surgically, and when they 259 00:12:11,106 --> 00:12:12,636 removed it, what would they find? 260 00:12:12,666 --> 00:12:16,236 Well, seeds and nuts and corn and popcorn stuck in the diverticula. 261 00:12:16,626 --> 00:12:19,716 And so, at least the logical inference there was that those 262 00:12:19,716 --> 00:12:21,306 things were causative, but. 263 00:12:21,781 --> 00:12:25,531 Since there's less surgery being done and a lot more colonoscopies, 264 00:12:25,531 --> 00:12:28,801 most gastroenterologists will tell you they go into a colonoscopy 265 00:12:28,801 --> 00:12:29,581 and guess what they see? 266 00:12:29,761 --> 00:12:32,611 Seeds and nuts and popcorn stuck in diverticula and they're 267 00:12:32,611 --> 00:12:33,991 not infected or inflamed. 268 00:12:33,991 --> 00:12:39,481 So it may not be that kind of causal link that we were worried about or educated 269 00:12:39,481 --> 00:12:40,981 about for such a long period of time. 270 00:12:41,251 --> 00:12:44,511 Fiber in general, whether it's high residue or low residue, 271 00:12:44,511 --> 00:12:47,335 so a little bit more digestible fiber, is probably important. 272 00:12:47,375 --> 00:12:51,815 The author cites that there's kind of back and forth research in terms of whether 273 00:12:51,815 --> 00:12:57,105 a high fiber diet decreases attacks of diverticulitis, but it does seem to 274 00:12:57,315 --> 00:13:01,935 alleviate diverticulosis in general and kind of prevent some of the complications. 275 00:13:02,185 --> 00:13:04,435 And that's because it decreases intraluminal pressure. 276 00:13:04,435 --> 00:13:07,705 It kind of keeps stuff passing through the colon and it's a little bit less 277 00:13:07,705 --> 00:13:11,121 likely and it's just a good thing in general anyway, high fiber diet is. 278 00:13:11,481 --> 00:13:15,081 If it were the diet that helped this or something that were unhealthy, I think 279 00:13:15,081 --> 00:13:17,121 it'd be a lot harder to recommend that. 280 00:13:17,121 --> 00:13:20,071 Whether the evidence shows that you're never gonna have diverticulitis 281 00:13:20,091 --> 00:13:22,191 if you eat a high fiber diet, I don't think that's there. 282 00:13:22,591 --> 00:13:27,211 We talked about treating patients without antibiotics when they 283 00:13:27,211 --> 00:13:29,911 have mild diverticular disease and they're not high risk. 284 00:13:29,911 --> 00:13:32,731 But one of the things that is felt to be important for them 285 00:13:32,731 --> 00:13:34,231 is to really kind of cut back. 286 00:13:34,231 --> 00:13:38,161 So give them some relative bowel rest as part of their treatment, whether 287 00:13:38,161 --> 00:13:39,481 they're on some antibiotics or not. 288 00:13:39,631 --> 00:13:43,231 So that would be like clear liquids for a couple of days, and then 289 00:13:43,231 --> 00:13:47,217 easing back into a fiber rich diet as they start to feel better. 290 00:13:47,607 --> 00:13:50,847 So those are kind of the important dietary things to keep in mind. 291 00:13:51,297 --> 00:13:53,817 And this kind of leads into another concept that I think 292 00:13:53,817 --> 00:13:54,807 you're gonna talk about. 293 00:13:55,117 --> 00:13:58,724 What's going into our mouth and how it affects our microbiome and, 294 00:13:58,724 --> 00:14:02,876 fiber, not only as a bulk agent, but also some forms of fiber or 295 00:14:02,876 --> 00:14:04,638 prebiotic can affect our gut flora. 296 00:14:04,848 --> 00:14:09,495 And, again, thinking about pathophysiology and is it really obstructive 297 00:14:09,495 --> 00:14:13,455 mechanical type things that's causing diverticulitis or is it more biological? 298 00:14:13,455 --> 00:14:14,685 Is it microbiome related? 299 00:14:15,075 --> 00:14:16,825 Kind of some interesting stuff there, don't you think? 300 00:14:17,335 --> 00:14:19,208 Tracey: Yeah that was really interesting to me too. 301 00:14:19,232 --> 00:14:22,112 We never really thought much about our microbiome, and now all of a sudden 302 00:14:22,112 --> 00:14:26,062 we're finding all these things that it's becoming extremely important too. 303 00:14:26,197 --> 00:14:30,377 You know, just the antibiotic stewardship alone, you're killing off or changing 304 00:14:30,377 --> 00:14:34,712 your microbiome and the long reaching effects are of that and how many different 305 00:14:34,712 --> 00:14:36,332 things that really affects in your body. 306 00:14:36,782 --> 00:14:40,682 One of the emerging researches is saying that your gut dysbiosis that 307 00:14:40,682 --> 00:14:44,322 can even occur when you're younger from antibiotics when you're younger or from 308 00:14:44,322 --> 00:14:48,905 your dietary habits when you're younger can influence turning out to have 309 00:14:48,905 --> 00:14:50,795 diverticular disease when you're older. 310 00:14:51,075 --> 00:14:54,095 When I trained, I always thought, you know, chronic constipation and 311 00:14:54,095 --> 00:14:57,915 strain on stool is what pop those little diverticula into your colon. 312 00:14:58,365 --> 00:15:01,805 But now the thoughts is that that may contribute somewhat, because of 313 00:15:01,805 --> 00:15:04,895 the lack of a fiber diet, but it may actually have to do with the bacteria 314 00:15:04,895 --> 00:15:06,215 that are living in your intestines. 315 00:15:06,675 --> 00:15:11,120 So, strains of lactobacillus and bifidobacterium specifically are being 316 00:15:11,120 --> 00:15:15,130 studied currently, as an imbalance of those in your colon may predispose you 317 00:15:15,130 --> 00:15:17,550 to be getting diverticulum as you age. 318 00:15:17,860 --> 00:15:19,870 One thing we didn't really mention is age. 319 00:15:19,930 --> 00:15:23,140 It's really weird to see diverticulosis in kids. 320 00:15:23,140 --> 00:15:26,530 I mean, it does happen in diverticulitis, in kids, but it's so rare. 321 00:15:26,530 --> 00:15:28,955 I can honestly say I've never seen it in anybody that's 322 00:15:28,955 --> 00:15:31,317 probably younger than 35 or 40. 323 00:15:31,647 --> 00:15:35,817 So as you age, that constant use of your colon, the constant dietary 324 00:15:35,817 --> 00:15:39,989 changes, the changes with your microbiome predispose you to developing 325 00:15:39,989 --> 00:15:41,551 these diverticulitis over time. 326 00:15:41,551 --> 00:15:43,890 It's kinda like arthritis of your intestines. 327 00:15:44,260 --> 00:15:44,920 Joe: Exactly. 328 00:15:44,920 --> 00:15:45,970 Wear and tear change. 329 00:15:46,280 --> 00:15:46,610 Tracey: Yeah. 330 00:15:46,610 --> 00:15:50,070 'Cause if we went and we scanned everybody who was 25, most people 331 00:15:50,070 --> 00:15:52,620 probably wouldn't have too many diverticulum, but if you went and 332 00:15:52,620 --> 00:15:56,430 scanned everybody who's 85, probably 90% of them would've some diverticulum. 333 00:15:56,780 --> 00:15:59,720 So yeah, age is another thing that obviously is an 334 00:15:59,720 --> 00:16:00,950 increased risk factor for it. 335 00:16:01,290 --> 00:16:04,400 But something more that you want to think about in an older person as a 336 00:16:04,400 --> 00:16:06,950 part of your differential diagnosis rather than a younger person. 337 00:16:07,220 --> 00:16:09,063 You did mention pregnancy , that's another thing. 338 00:16:09,143 --> 00:16:11,123 Diverticulitis can occur in pregnancy. 339 00:16:11,553 --> 00:16:14,197 Again, I don't think I've ever seen it, but definitely something that should 340 00:16:14,197 --> 00:16:16,942 be on your differential diagnosis because there's a lot more challenges 341 00:16:16,942 --> 00:16:18,952 to that of how you diagnose it. 342 00:16:18,952 --> 00:16:22,132 It's not your basic standard, left lower quadrant abdominal pain. 343 00:16:22,488 --> 00:16:25,848 It can be other things because of the way the uterus displaces the colon. 344 00:16:26,222 --> 00:16:30,632 so something that you really kind of have to have on your radar to think about it. 345 00:16:30,632 --> 00:16:34,052 Maybe if somebody had had it before you would think of it, or if it was a what 346 00:16:34,052 --> 00:16:35,882 they're now calling geriatric pregnancies. 347 00:16:35,882 --> 00:16:38,372 You know, if somebody called me a geriatric pregnancy when I was 348 00:16:38,372 --> 00:16:39,562 pregnant, I would've been really mad. 349 00:16:40,322 --> 00:16:40,802 Joe: Slap 350 00:16:41,362 --> 00:16:41,832 Tracey: I know, right? 351 00:16:43,682 --> 00:16:45,902 Yeah, I had my first in my thirties, I think that made 352 00:16:45,902 --> 00:16:47,285 me geriatric, but whatever. 353 00:16:47,348 --> 00:16:50,238 Yeah, so, wrapping back around, we were talking about microbiomes. 354 00:16:50,258 --> 00:16:51,985 So, yeah more to come on this. 355 00:16:51,985 --> 00:16:54,955 You know, I don't think there's any evidence that says we should be giving 356 00:16:54,955 --> 00:16:57,919 everybody bacteria to eat to fix their diverticulitis or diverticulosis 357 00:16:59,525 --> 00:17:02,029 . But, definitely something that's really emerging research and that 358 00:17:02,029 --> 00:17:03,958 we'll probably be seeing more of 359 00:17:04,688 --> 00:17:05,018 Joe: Yep. 360 00:17:05,428 --> 00:17:05,878 Tracey: What else? 361 00:17:06,578 --> 00:17:07,478 Joe: Pain control, right? 362 00:17:07,478 --> 00:17:08,998 This is a pretty painful condition. 363 00:17:08,998 --> 00:17:12,818 One of the main reasons why people seek care is that it hurts. 364 00:17:12,818 --> 00:17:16,318 Well, in addition to kind of making the right diagnosis and identifying 365 00:17:16,318 --> 00:17:19,618 our high risk patients and sending them along, anybody that we're 366 00:17:19,618 --> 00:17:23,208 able to send home, in addition to talking to them about antibiotics, no 367 00:17:23,208 --> 00:17:26,428 antibiotics and the dietary changes, clear liquid diet, that sort of thing, 368 00:17:26,698 --> 00:17:28,078 how are we gonna manage their pain? 369 00:17:28,388 --> 00:17:31,628 Tylenol's kind of the easiest, probably safest thing to recommend. 370 00:17:31,848 --> 00:17:35,298 For many things we see in urgent care, NSAIDs are reasonable 371 00:17:35,298 --> 00:17:37,248 choices, but really not here. 372 00:17:37,528 --> 00:17:40,585 It increases the risk of perforation and bleeding. 373 00:17:40,745 --> 00:17:43,965 These patients have a basically inflamed colonic mucosa. 374 00:17:43,965 --> 00:17:46,965 So the risks go way up with using NSAIDs in these patients. 375 00:17:47,445 --> 00:17:48,555 So we need to keep that in mind. 376 00:17:48,555 --> 00:17:52,975 It can't be sort of a knee jerk, here take ibuprofen, Tylenol, or combination. 377 00:17:53,005 --> 00:17:55,846 We really need to avoid it in really any patient, not just those 378 00:17:55,846 --> 00:17:59,186 other groups of patients that we consider to be NSAID sensitive. 379 00:17:59,576 --> 00:18:03,056 We should really consider all of our diverticulitis patients NSAID sensitive. 380 00:18:03,056 --> 00:18:04,806 I don't think there's tons of evidence about that. 381 00:18:04,806 --> 00:18:07,386 But it's a theoretical concern and something we should keep in mind. 382 00:18:07,756 --> 00:18:12,006 I would say occasionally get that patient who's super uncomfortable, most of 383 00:18:12,006 --> 00:18:13,716 those patients are not gonna go home. 384 00:18:14,056 --> 00:18:17,196 But if they are gonna go home if you are able to do the workup and 385 00:18:17,196 --> 00:18:20,056 determine that there's no complication and they're not a high risk 386 00:18:20,056 --> 00:18:21,136 patient, then they were to go home. 387 00:18:21,136 --> 00:18:25,036 But in more severe pain, that's where you might, might, might consider 388 00:18:25,036 --> 00:18:26,956 opioids, but really short term. 389 00:18:26,956 --> 00:18:30,126 I mean, that's gonna actually complicate things, increase their intraluminal 390 00:18:30,126 --> 00:18:33,811 pressure and it, it might be something you might say, I'm never gonna do, and 391 00:18:33,811 --> 00:18:36,961 if somebody has pain that bad, they're just gonna have to go to the ED to get 392 00:18:36,961 --> 00:18:38,851 it sorted out or have to be admitted. 393 00:18:39,191 --> 00:18:41,501 But I think if they end up getting admitted, they're probably gonna 394 00:18:41,501 --> 00:18:43,181 get IV opioids in that case. 395 00:18:43,211 --> 00:18:47,721 Although, I will say, gosh, in my ED practice, IV 396 00:18:47,773 --> 00:18:50,173 acetaminophen is just incredible. 397 00:18:50,623 --> 00:18:51,523 Tracey: Love that stuff. 398 00:18:51,653 --> 00:18:57,733 Joe: I don't know why it works so much better for any kind of pain than oral, and 399 00:18:57,733 --> 00:19:00,763 I don't know if it's because it all gets in there at the same time or what, but 400 00:19:00,869 --> 00:19:02,939 it's my first choice in a lot of patients. 401 00:19:02,963 --> 00:19:04,043 You know, even moderate pain. 402 00:19:04,043 --> 00:19:06,063 And I'll talk to them and say, look, we're gonna try this first 403 00:19:06,063 --> 00:19:07,203 and let's see if you feel better. 404 00:19:07,573 --> 00:19:09,463 And then we can always give you stronger stuff, but it's 405 00:19:09,463 --> 00:19:11,269 incredible how well that works. 406 00:19:11,269 --> 00:19:14,259 I wish we had something like it in urgent care 'cause it's 407 00:19:14,259 --> 00:19:16,066 safe and, super effective. 408 00:19:16,116 --> 00:19:18,936 But anyway, that's a little bit different than what we're talking about here. 409 00:19:18,936 --> 00:19:23,026 So anyway, the key messages, avoid NSAIDs in diverticular disease. 410 00:19:23,261 --> 00:19:26,101 Tracey: Yeah, I would also say, the narcotics as well if you're sending 411 00:19:26,101 --> 00:19:28,021 the patient home, for a couple reasons. 412 00:19:28,021 --> 00:19:32,491 One, the constipation issue, but also it theoretically could mask symptoms. 413 00:19:32,891 --> 00:19:35,051 Opioids don't alleviate pain completely. 414 00:19:35,051 --> 00:19:37,181 We used to say, don't ever give an opioid to an abdominal 415 00:19:37,181 --> 00:19:38,321 pain you haven't worked up yet. 416 00:19:38,661 --> 00:19:41,398 But I think some of that does ring true because if they're feeling a little 417 00:19:41,398 --> 00:19:43,805 bit better, they may not realize that they're getting a little bit worse 418 00:19:43,938 --> 00:19:46,802 . And that might be something that you're a little bit concerned about. 419 00:19:47,141 --> 00:19:50,997 In my humble opinion if you think that patient is sick enough that they 420 00:19:50,997 --> 00:19:53,977 need narcotics for pain control, you probably should be sending them to 421 00:19:53,977 --> 00:19:55,568 the E D and not sending them home. 422 00:19:56,128 --> 00:19:59,428 And if they're refusing to go to the ED and they want pain medication, then 423 00:19:59,428 --> 00:20:02,738 that's even more of a reason because, you know that person's probably not 424 00:20:02,738 --> 00:20:04,338 gonna do what you say in the first place. 425 00:20:04,338 --> 00:20:06,118 Joe: Focusing wrong priorities. 426 00:20:06,258 --> 00:20:06,428 Yeah. 427 00:20:06,728 --> 00:20:08,768 Tracey: You don't wanna give them more ammunition to avoid 428 00:20:08,768 --> 00:20:10,058 going to the emergency room. 429 00:20:10,428 --> 00:20:12,408 Joe: I mean, I would never do it with a clinical diagnosis. 430 00:20:12,408 --> 00:20:15,618 I think anyone to know that there's no complication and it would basically 431 00:20:15,618 --> 00:20:19,368 facilitate outpatient management only, and it's not a routine thing. 432 00:20:19,368 --> 00:20:20,448 I agree with you a hundred percent. 433 00:20:20,875 --> 00:20:22,855 It complicates any kind of GI pain really. 434 00:20:23,848 --> 00:20:25,648 Tracey: Let's talk about some of the complications here. 435 00:20:25,648 --> 00:20:27,808 What happens if you miss that diverticulitis and 436 00:20:27,808 --> 00:20:28,948 you send that person home? 437 00:20:28,998 --> 00:20:32,358 What kind of horrible things can they end up with that would be a don't miss. 438 00:20:32,998 --> 00:20:35,358 Joe: Well, they could get better, even without antibiotics, right? 439 00:20:35,758 --> 00:20:36,388 Tracey: Yeah, right. 440 00:20:36,538 --> 00:20:39,258 Joe: But if not, if they were to progress, the kind of first 441 00:20:39,715 --> 00:20:41,485 complication that can occur. 442 00:20:41,535 --> 00:20:43,965 I mean, if you don't have somebody who gets overwhelming sepsis and a 443 00:20:43,965 --> 00:20:48,555 physiologic type complication, would be a local complication of microperforation 444 00:20:48,945 --> 00:20:52,995 where that pressure inside the diverticula rises the inflammation 445 00:20:52,995 --> 00:20:54,585 of the wall of the diverticula. 446 00:20:54,795 --> 00:20:58,495 Again, these are actually, in the pathophysiology, these don't have 447 00:20:58,495 --> 00:21:02,245 that muscular layer, so it's a thinner wall structure than the gut itself. 448 00:21:02,695 --> 00:21:05,665 A lot more likely to perforate, especially if it's infected or inflamed. 449 00:21:05,845 --> 00:21:08,990 So the first thing that would happen would be a small, you could even consider 450 00:21:08,990 --> 00:21:12,765 it microscopic, perf or a perf that couldn't be seen with a naked eye. 451 00:21:12,765 --> 00:21:16,308 You get bowel contents going into the adjacent peritoneal space 452 00:21:16,308 --> 00:21:19,378 around the diverticulum, and you get localized inflammation and 453 00:21:19,438 --> 00:21:21,088 really a localized peritonitis. 454 00:21:21,568 --> 00:21:26,343 What we know from situations where that is identified, let's say 455 00:21:26,343 --> 00:21:28,413 on CT, nothing worse than that. 456 00:21:28,623 --> 00:21:30,813 That's usually amenable to antibiotics. 457 00:21:30,843 --> 00:21:34,443 A lot of times when you see that micro perf on CT, most gastroenterologists 458 00:21:34,443 --> 00:21:36,663 that I talk with, and I think most of the evidence, says those 459 00:21:36,663 --> 00:21:41,313 patients need to be in the hospital on IV antibiotics for two reasons. 460 00:21:42,013 --> 00:21:43,993 The IV antibiotics are a lot stronger. 461 00:21:43,993 --> 00:21:48,363 You can give higher doses parenterally with fewer complications, but also really 462 00:21:48,363 --> 00:21:52,623 to observe them for worsening because the next step in that complication 463 00:21:52,623 --> 00:21:56,983 is that that perforation and leakage of bowel contents into the peritoneal 464 00:21:56,983 --> 00:22:02,128 cavity becomes more extensive or occurs in multiple diverticula and 465 00:22:02,128 --> 00:22:05,798 the body's immune system is not able to contain it, you'll get abscess 466 00:22:05,798 --> 00:22:11,768 formation, which is just basically a more extensive process from perforation. 467 00:22:12,168 --> 00:22:16,028 Once those abscesses get to be about four centimeters in diameter. 468 00:22:16,423 --> 00:22:20,193 Most of the time most specialists are gonna want to do something to drain them. 469 00:22:20,533 --> 00:22:24,583 Smaller abscesses, again, amenable, like micro perforation and localized 470 00:22:24,583 --> 00:22:27,493 inflammation, to IV antibiotics, bowel rest, that kind of thing. 471 00:22:27,953 --> 00:22:30,503 But once your abscess gets big enough, it's kind of a surface 472 00:22:30,503 --> 00:22:32,303 area to volume sort of thing. 473 00:22:32,353 --> 00:22:35,253 Antibiotics in our immune system operate on the area. 474 00:22:35,413 --> 00:22:37,258 They only get into the outside of it. 475 00:22:37,258 --> 00:22:38,548 They can't get into the inside. 476 00:22:38,948 --> 00:22:42,105 And based on studies, that four centimeter diameter is enough for 477 00:22:42,105 --> 00:22:44,955 somebody to want to drain that and collapse it, get rid of that volume. 478 00:22:45,415 --> 00:22:49,675 Used to be a surgical thing, but now a lot of times it can be done percutaneously 479 00:22:49,675 --> 00:22:52,975 and interventional radiologists can go through the abdominal wall. 480 00:22:53,675 --> 00:22:57,155 I've actually seen them go through the back in situations where the 481 00:22:57,425 --> 00:23:01,625 abscess was located more posteriorly and then they can insert a drain which 482 00:23:01,625 --> 00:23:03,155 will help that patient get better. 483 00:23:03,545 --> 00:23:07,995 And then, I had mentioned it earlier on about surgery actually entering the 484 00:23:08,148 --> 00:23:10,040 abdomen laparoscopically or open surgery. 485 00:23:10,550 --> 00:23:14,074 Before there were good antibiotics that was the treatment of diverticulitis that 486 00:23:14,074 --> 00:23:17,764 wasn't getting better with bowel rest and whatever antibiotics there were. 487 00:23:18,074 --> 00:23:19,694 Now it's pretty rare. 488 00:23:19,744 --> 00:23:23,604 If a patient fails those other treatments then they're a candidate for surgery. 489 00:23:23,624 --> 00:23:26,444 And there are a couple of other reasons why a surgeon might take a patient 490 00:23:26,444 --> 00:23:28,617 to the operating room earlier on. 491 00:23:28,927 --> 00:23:34,747 Patients who have strictures as a result of their multiple diverticulitis episodes 492 00:23:35,107 --> 00:23:36,577 would be a candidate for removal of that. 493 00:23:36,577 --> 00:23:39,937 And anybody with recurrent diverticulitis, particularly any young person, I think 494 00:23:39,937 --> 00:23:44,337 they recommend surgical resection of that area just because they're more 495 00:23:44,337 --> 00:23:45,777 likely to get it over and over again. 496 00:23:45,777 --> 00:23:48,907 So surgeries used to be a lot more common, still used in those 497 00:23:48,907 --> 00:23:50,437 more complicated situations. 498 00:23:51,137 --> 00:23:51,407 Tracey: Yep. 499 00:23:51,467 --> 00:23:55,144 So if you miss it and they get worse, well most of the time 500 00:23:55,144 --> 00:23:55,924 they'll probably get better. 501 00:23:56,314 --> 00:23:59,274 Um, but the complications of getting worse would be, we were talking 502 00:23:59,274 --> 00:24:02,897 about perforation and abscess , so probably don't wanna miss that. 503 00:24:02,897 --> 00:24:06,717 So if patients, if they've come back to you a couple times, maybe CT 504 00:24:06,717 --> 00:24:09,087 scan, timely fashion of a CT scan. 505 00:24:09,087 --> 00:24:11,787 Obviously if you've got any of those high risk things, you probably 506 00:24:11,787 --> 00:24:14,647 should send them to the ED so they can get their CT same day. 507 00:24:15,047 --> 00:24:16,907 Some people, you're kind of sitting on the fence. 508 00:24:16,907 --> 00:24:18,107 They have some good follow up. 509 00:24:18,107 --> 00:24:20,297 Maybe you send them home on some antibiotics, they should 510 00:24:20,297 --> 00:24:21,767 have a CT scan at some point. 511 00:24:22,257 --> 00:24:24,387 It's okay to do as an outpatient in a day or two. 512 00:24:24,387 --> 00:24:25,737 It doesn't have to be right away. 513 00:24:26,077 --> 00:24:30,440 But if the diagnosis is in question in any way, shape, or form, or if they're 514 00:24:30,440 --> 00:24:33,560 not improving at the speed that you would like then they probably should 515 00:24:33,560 --> 00:24:35,210 have a CT at least as an outpatient. 516 00:24:35,410 --> 00:24:38,050 You know, if you're in an urgent care setting where you're capable of ordering 517 00:24:38,050 --> 00:24:42,000 those things, it might be worth ordering it or contacting their primary care doctor 518 00:24:42,270 --> 00:24:45,060 or telling them to call their primary care doctor or their GI doctor to 519 00:24:45,060 --> 00:24:47,250 get that CT scan in a timely fashion. 520 00:24:47,804 --> 00:24:50,656 For all kinds of abdominal pains, I cannot mention enough 521 00:24:51,046 --> 00:24:52,756 how useful serial exams are. 522 00:24:53,116 --> 00:24:56,446 Just like we do blood pressures multiple times to try and get a good picture 523 00:24:56,446 --> 00:25:00,196 of what's going on, examine the belly multiple times to see what's going on. 524 00:25:00,196 --> 00:25:02,820 So, you tell that patient when they're discharged, things 525 00:25:02,820 --> 00:25:04,740 that you should seek care for. 526 00:25:04,740 --> 00:25:08,120 Worsening pain, fever, signs of abscess or peritonitis, 527 00:25:08,120 --> 00:25:09,420 so your pain's getting worse. 528 00:25:09,750 --> 00:25:11,580 I tell 'em you can't stand up straight. 529 00:25:11,580 --> 00:25:14,130 You can't jump up and down because your belly hurts too much. 530 00:25:14,460 --> 00:25:16,170 You're curled up in a ball in the bed. 531 00:25:16,493 --> 00:25:19,383 You get a new fever, all of these things are bad things. 532 00:25:19,383 --> 00:25:21,346 That means you need a new exam by somebody. 533 00:25:21,346 --> 00:25:24,406 Somebody needs to lay hands on you to make sure you're not getting worse. 534 00:25:24,736 --> 00:25:27,826 Come back, go to the emergency room, have your primary care doctor see you. 535 00:25:28,206 --> 00:25:30,936 The more times people examine that belly to make sure things are getting 536 00:25:30,936 --> 00:25:32,656 better and not worse , is a good thing. 537 00:25:33,096 --> 00:25:33,516 Joe: Mm-hmm. 538 00:25:33,711 --> 00:25:36,751 Tracey: And then, again, we mentioned things like patients who 539 00:25:36,751 --> 00:25:38,971 are elderly, immunocompromised. 540 00:25:38,971 --> 00:25:42,301 If the diagnosis is in question in any way, shape or form, you're not sure 541 00:25:42,301 --> 00:25:44,911 you quite have a handle of what's going on and you're really concerned about 542 00:25:44,911 --> 00:25:48,731 that patient, always err on the side of caution and send that patient forward 543 00:25:48,731 --> 00:25:50,411 to the ED for further evaluation. 544 00:25:50,691 --> 00:25:53,936 Most of the time they'll end up getting a scan but even just having a 545 00:25:53,936 --> 00:25:58,110 second set of eyes or a second person evaluate the patient is not a bad thing. 546 00:25:58,360 --> 00:26:01,480 We didn't talk about lab work , not everybody needs lab work for this. 547 00:26:01,480 --> 00:26:03,657 Most people don't immediately need lab work for this. 548 00:26:03,657 --> 00:26:06,630 But you know, if there's any concern, they're gonna get the lab work in the ED. 549 00:26:06,906 --> 00:26:08,411 We also didn't talk about UAs. 550 00:26:08,636 --> 00:26:11,764 Urinalysis might be a useful thing if you're trying to figure out, 551 00:26:11,764 --> 00:26:15,304 is this diverticulitis or is this some sort of urinary concern? 552 00:26:15,939 --> 00:26:16,469 Pregnancy tests, 553 00:26:16,469 --> 00:26:18,229 Joe: Pregnancy test for sure. 554 00:26:18,489 --> 00:26:20,987 Tracey: Yeah, if the patient's potentially pregnant, but like I 555 00:26:20,987 --> 00:26:23,935 said, I can't remember the last time I saw diverticulitis in 556 00:26:23,935 --> 00:26:25,482 somebody with a childbearing age. 557 00:26:25,666 --> 00:26:27,061 It doesn't occur that often. 558 00:26:27,551 --> 00:26:29,126 But definitely something that you should think about. 559 00:26:30,322 --> 00:26:32,652 Joe: Yeah, I was trying to think about some of the patients through the years 560 00:26:32,652 --> 00:26:37,302 who I've just kind of exclusively taken care of in urgent care with 561 00:26:37,402 --> 00:26:40,750 diverticulitis and there've been enough that it's not something that I can 562 00:26:40,750 --> 00:26:42,500 say that I've never done before. 563 00:26:42,550 --> 00:26:46,990 The author cites, I guess, sensitivity and specificity in the mid sixties 564 00:26:46,990 --> 00:26:48,940 for history and physical alone. 565 00:26:49,640 --> 00:26:51,860 But they don't specifically say whether the patient, if they've 566 00:26:51,860 --> 00:26:53,240 had diverticulitis before. 567 00:26:53,240 --> 00:26:56,184 I think that that is kind of a big factor for me. 568 00:26:56,184 --> 00:26:59,124 I can't say that it's necessarily evidence-based, but you have 569 00:26:59,124 --> 00:27:02,710 somebody you know, what do they say, sounds like a duck, walks like 570 00:27:02,710 --> 00:27:05,770 a duck, quacks like a duck, and the person's had the duck before. 571 00:27:07,043 --> 00:27:13,193 Um, I think you can safely do that because people can have diverticulitis and 572 00:27:13,193 --> 00:27:17,747 have normal labs and their urine may be abnormal and it shouldn't dissuade you. 573 00:27:18,227 --> 00:27:21,077 The main thing is making the decision, do I need imaging to, 574 00:27:21,077 --> 00:27:22,487 number one, make the diagnosis? 575 00:27:22,832 --> 00:27:26,378 Because the patient's never had it before and it's not super clear based 576 00:27:26,378 --> 00:27:30,818 on their h and p or do I need the CT because I'm worried about a complication? 577 00:27:30,818 --> 00:27:33,008 Yeah, this is diverticulitis, I'm pretty sure, and I'm worried 578 00:27:33,008 --> 00:27:34,178 this person has a complication. 579 00:27:34,178 --> 00:27:36,552 So those are maybe the decisions. 580 00:27:36,762 --> 00:27:40,707 And I was thinking if I had to do any test, again, to make sure I could 581 00:27:40,707 --> 00:27:44,127 send somebody home, it would be a pregnancy test to make sure, not 582 00:27:44,127 --> 00:27:46,947 necessarily that they were pregnant with diverticulitis, but that pregnancy 583 00:27:46,947 --> 00:27:48,810 wasn't masquerading some complication. 584 00:27:48,983 --> 00:27:49,643 I think we're lucky. 585 00:27:49,643 --> 00:27:54,223 You had talked about age and people are more likely to have diverticula 586 00:27:54,223 --> 00:27:57,313 as they get older, so it's not necessarily a younger person's disease. 587 00:27:57,313 --> 00:28:01,003 So we're somewhat maybe saved by that in that it doesn't occur that 588 00:28:01,003 --> 00:28:05,823 much during pregnancy or in women of childbearing potential so that it's 589 00:28:05,823 --> 00:28:09,723 not necessarily in the differential as much, but it can still happen. 590 00:28:09,723 --> 00:28:10,468 So you gotta keep it in mind. 591 00:28:11,218 --> 00:28:11,518 Tracey: Right. 592 00:28:11,698 --> 00:28:15,638 So in closing let's just mention, diverticulitis diverticular disease. 593 00:28:15,758 --> 00:28:19,238 They're not gonna walk in there with an arrow pointing to their lower quadrant and 594 00:28:19,238 --> 00:28:21,008 saying, I have diverticulitis right here. 595 00:28:21,398 --> 00:28:25,648 Presentations can be very variable, so you really have to use your detective skills, 596 00:28:25,703 --> 00:28:29,633 getting that good history, that good physical, to figure out what's going on. 597 00:28:30,003 --> 00:28:31,443 Not everybody needs an image. 598 00:28:31,443 --> 00:28:34,933 Not everybody needs antibiotics, but being smart about who does and who 599 00:28:34,933 --> 00:28:39,043 doesn't , is really key to trying and managing these people appropriately. 600 00:28:39,383 --> 00:28:42,733 Really think thoughtfully about it before you make any decisions about 601 00:28:42,733 --> 00:28:43,993 what you're gonna do with the patient. 602 00:28:43,993 --> 00:28:45,223 I always say, go with your gut. 603 00:28:45,223 --> 00:28:47,563 If you think there's something wrong, there's, you know, there's. 604 00:28:47,978 --> 00:28:48,668 Exactly. 605 00:28:48,968 --> 00:28:52,328 There's probably something wrong and there's nothing wrong with having 606 00:28:52,478 --> 00:28:55,837 that person be evaluated in the ED and confirming or negating the 607 00:28:55,922 --> 00:28:57,747 fact that they have diverticulitis. 608 00:28:58,443 --> 00:28:59,013 . Joe: There you go. 609 00:28:59,288 --> 00:29:00,758 Tracey: Any other closing thoughts? 610 00:29:01,458 --> 00:29:03,198 Joe: No, I think we covered it pretty well. 611 00:29:03,258 --> 00:29:06,371 I'm gonna read this issue again because of the microbiome stuff. 612 00:29:06,551 --> 00:29:09,281 I think it's something I'm just becoming more interested in, 613 00:29:09,281 --> 00:29:10,511 in general in terms of health. 614 00:29:10,668 --> 00:29:14,298 It's sort of a naturopath kind of thing, the naturopaths have been focused on 615 00:29:14,298 --> 00:29:20,058 that sort of for a while, but it seems to be more important in some of our 616 00:29:20,058 --> 00:29:23,908 allopathic diseases and understanding it, the classic change in microbiome 617 00:29:23,908 --> 00:29:26,818 with c diff, gosh, you take an antibiotic, it changes your microbiome, 618 00:29:26,818 --> 00:29:28,318 you get this terrible diarrhea, right? 619 00:29:28,658 --> 00:29:32,678 But with the idea that there's more bacteria in our gut than there are 620 00:29:32,678 --> 00:29:37,082 living cells in our body, it's probably gotta be important in a lot of ways that 621 00:29:37,082 --> 00:29:38,936 we are still beginning to understand. 622 00:29:39,266 --> 00:29:43,346 So the fact that the pathophysiology might be based on that and that maybe some 623 00:29:43,346 --> 00:29:47,576 treatments might be that you could take a probiotic or a prebiotic or something and 624 00:29:47,576 --> 00:29:49,106 maybe get better is kind of interesting. 625 00:29:49,126 --> 00:29:52,191 And I look forward to seeing if that gets born out with the research. 626 00:29:52,891 --> 00:29:53,371 Tracey: All right. 627 00:29:53,371 --> 00:29:54,031 Sounds great. 628 00:29:54,151 --> 00:29:55,141 Joe: What are we doing next month? 629 00:29:55,141 --> 00:29:55,741 Do you know yet? 630 00:29:56,266 --> 00:29:56,956 Tracey: I do. 631 00:29:57,056 --> 00:29:59,231 It's yours truly does low back pain. 632 00:29:59,736 --> 00:30:00,846 Joe: Oh, nice. 633 00:30:00,846 --> 00:30:02,076 I get to interrogate you then 634 00:30:02,076 --> 00:30:02,146 Yeah. 635 00:30:02,176 --> 00:30:03,671 Tracey: So you do get to interrogate me. 636 00:30:03,671 --> 00:30:05,031 It's payback s a you know what. 637 00:30:05,441 --> 00:30:06,851 Yeah, one of my favorite topics. 638 00:30:06,851 --> 00:30:08,231 It's a love hate relationship. 639 00:30:08,281 --> 00:30:08,911 Just to share. 640 00:30:08,911 --> 00:30:10,831 I've had horrible back pain my whole life. 641 00:30:10,831 --> 00:30:12,451 Multiple surgeries, whole nine yards. 642 00:30:12,451 --> 00:30:15,528 And I think people don't do back pain justice, you know, they don't treat 643 00:30:15,528 --> 00:30:16,908 it with the respect that it deserves. 644 00:30:17,208 --> 00:30:22,409 And there's also an educational gap as to how to explain to people back pain. 645 00:30:22,779 --> 00:30:24,189 And I know it's really frustrating. 646 00:30:24,189 --> 00:30:26,349 I mean, in the two thousands we're all like, oh, they're 647 00:30:26,349 --> 00:30:27,939 just drug seekers, you know? 648 00:30:27,939 --> 00:30:30,609 And a part of that was our own fault in emergency room, giving 649 00:30:30,609 --> 00:30:32,029 them, pain is the fifth vital sign. 650 00:30:32,119 --> 00:30:32,989 Don't get me started with that. 651 00:30:33,076 --> 00:30:35,746 But yeah, so I think it'll be an interesting article about ruling 652 00:30:35,746 --> 00:30:39,001 out red flags and really going over the evidence with what treatments 653 00:30:39,001 --> 00:30:40,291 work and what treatments don't work. 654 00:30:40,291 --> 00:30:42,771 And I bet you're gonna find a few things that are going to surprise you. 655 00:30:42,771 --> 00:30:45,167 Maybe not you Joe, but maybe our listeners 656 00:30:45,167 --> 00:30:45,487 Joe: I can't wait. 657 00:30:45,487 --> 00:30:46,342 I'm looking forward to it. 658 00:30:46,657 --> 00:30:47,047 Tracey: Me too. 659 00:30:47,527 --> 00:30:48,907 Joe: Thanks listening everybody. 660 00:30:48,957 --> 00:30:51,237 Have a good month and we will talk to you soon. 661 00:30:51,918 --> 00:30:55,078 Tracey: I want to thank everybody to listening to this month's evidence based 662 00:30:55,078 --> 00:30:59,508 urgentology podcast . Just a reminder that subscribers can go to ebmedicine. 663 00:30:59,518 --> 00:31:03,318 net and read the full issue if you want more information, if you haven't already, 664 00:31:04,217 --> 00:31:06,107 Joe: And if you're not a subscriber head to the site. 665 00:31:06,277 --> 00:31:07,237 That's ebmedicine. 666 00:31:07,467 --> 00:31:09,047 net to check out what they have. 667 00:31:09,370 --> 00:31:12,980 If you subscribe you'll get access to the article as well as future articles 668 00:31:13,000 --> 00:31:15,600 and the whole archive of all past issues. 669 00:31:16,054 --> 00:31:17,204 Tracey: Look forward to seeing you there.