Smoke Enemas Are Not Used in Modern Diverticulitis Treatment
Smoke enemas (or "smog enemas") have no role in the contemporary management of diverticulitis and should never be used. This historical practice, which involved blowing tobacco smoke into the rectum, was abandoned in the 19th century and has no evidence base for treating any modern medical condition, including diverticulitis.
Current Evidence-Based Treatment for Diverticulitis
The management of diverticulitis is based on disease severity and complications, not on outdated historical practices:
For Uncomplicated Diverticulitis
- Outpatient management with observation is appropriate for clinically stable, afebrile patients, with only a 4.3% failure rate in meta-analyses 1
- Antibiotics may not be necessary in mild uncomplicated cases, as recent evidence shows they do not accelerate recovery or prevent complications in selected patients 1, 2
- CT imaging with IV contrast is the gold standard diagnostic test, achieving 98% accuracy for diverticulitis 3
For Complicated Diverticulitis with Pericolic Gas
- A trial of non-operative treatment with antibiotics is recommended for patients with CT findings of pericolic extraluminal gas located <5 cm from the affected colon segment 4, 1
- Close clinical monitoring is mandatory, as elevated CRP levels may predict treatment failure 4, 5
For Diverticular Abscesses
- Small abscesses (<4-5 cm): Initial antibiotic therapy alone for 7 days, with a 20% failure rate and 0.6% mortality 4, 5
- Large abscesses: Percutaneous drainage combined with antibiotics for 4 days in immunocompetent patients 5
- Surgical intervention is required if patients show worsening inflammatory signs or if the abscess doesn't respond to medical therapy 4, 5
For Diffuse Peritonitis
- Immediate surgical intervention with prompt fluid resuscitation and antibiotics is required for patients with diffuse peritonitis 4, 1
- Hartmann's procedure is preferred for unstable patients or those with multiple comorbidities 4
Critical Pitfall to Avoid
Contrast enemas are contraindicated in acute diverticulitis according to current guidelines 4, 3. While older literature from 1988 described their use 6, modern imaging with CT has completely replaced this practice because contrast enemas:
- Only show secondary effects of inflammation 3
- Miss extraluminal abnormalities like abscesses 3
- Increase perforation risk in acute diverticulitis 3
The only acceptable role for contrast studies mentioned in guidelines is for assessing colovesical fistulas in specific circumstances, not for acute diverticulitis management 4.